Provider Demographics
NPI:1336451970
Name:JOHNSON, PATRICIA ANN (CMT)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 W VENTURI DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-6008
Mailing Address - Country:US
Mailing Address - Phone:719-547-8482
Mailing Address - Fax:719-647-0398
Practice Address - Street 1:2131 JERRY MURPHY RD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-1262
Practice Address - Country:US
Practice Address - Phone:719-546-0037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-12
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9529172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO793912OtherASSOCIATED MASSAGE AND BODYWORK PROFESSIONALS
CO9529OtherSTATE OF CO, DIVISION OF REGISTRATIONS