Provider Demographics
NPI:1720061351
Name:JOHNSON, LAURIE (PT)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5982
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23471-0982
Mailing Address - Country:US
Mailing Address - Phone:757-351-6020
Mailing Address - Fax:757-351-6021
Practice Address - Street 1:5665 LOWERY RD
Practice Address - Street 2:#300
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-2220
Practice Address - Country:US
Practice Address - Phone:757-351-6020
Practice Address - Fax:757-351-6021
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305003714225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010380740Medicaid
VA010380758Medicaid
VA010381207Medicaid
VA010380766Medicaid
VA010381223Medicaid
VA008938741Medicaid
VA010380766Medicaid