Provider Demographics
NPI:1972740058
Name:JOHNSON, CAROL RENEE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:RENEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 N PINES RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-5176
Mailing Address - Country:US
Mailing Address - Phone:509-879-6025
Mailing Address - Fax:
Practice Address - Street 1:321 N PINES RD
Practice Address - Street 2:SUITE C
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-5176
Practice Address - Country:US
Practice Address - Phone:509-879-6025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-12
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00011653174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0242525OtherSTATE OF WASHINGTON LABOR AND INDUSTRIES