Provider Demographics
NPI:1205155413
Name:JOHNSON, CARROLL LOUISE (ATC/L)
Entity type:Individual
Prefix:MS
First Name:CARROLL
Middle Name:LOUISE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 NW 119TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114-7312
Mailing Address - Country:US
Mailing Address - Phone:405-326-3909
Mailing Address - Fax:
Practice Address - Street 1:409 NW 119TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-7312
Practice Address - Country:US
Practice Address - Phone:405-326-3909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-27
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK302352174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator