Provider Demographics
NPI:1356799738
Name:JOHNSON, MICHAEL (MAT, LAT, ATC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2007 RICE DR
Mailing Address - Street 2:
Mailing Address - City:LEVELLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79336-6705
Mailing Address - Country:US
Mailing Address - Phone:206-419-8568
Mailing Address - Fax:
Practice Address - Street 1:5309 39TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79414-1101
Practice Address - Country:US
Practice Address - Phone:206-419-8568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-26
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
20000240462255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer