Provider Demographics
NPI:1831415512
Name:JOHNSON, RENE' (CMT, LMT, MMP)
Entity type:Individual
Prefix:
First Name:RENE'
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CMT, LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 COLISEUM CROSSING
Mailing Address - Street 2:SUITE 216
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666
Mailing Address - Country:US
Mailing Address - Phone:757-842-9144
Mailing Address - Fax:
Practice Address - Street 1:700 BAKER ROAD
Practice Address - Street 2:SUITE 115
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462
Practice Address - Country:US
Practice Address - Phone:757-842-9144
Practice Address - Fax:757-873-1846
Is Sole Proprietor?:No
Enumeration Date:2010-04-20
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019007580174400000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No174400000XOther Service ProvidersSpecialist