Provider Demographics
NPI:1295091080
Name:JOHNSON, REBECA C (LMP)
Entity type:Individual
Prefix:MRS
First Name:REBECA
Middle Name:C
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11015 NE 4TH PLAIN SUITE B
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664
Mailing Address - Country:US
Mailing Address - Phone:360-892-0451
Mailing Address - Fax:360-892-1601
Practice Address - Street 1:11015 NE 4TH PLAIN SUITE B
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664
Practice Address - Country:US
Practice Address - Phone:360-892-0451
Practice Address - Fax:360-892-1601
Is Sole Proprietor?:No
Enumeration Date:2012-04-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60249677225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA 60246977OtherWASHINGTON STATE LICENSE