Provider Demographics
NPI:1841291366
Name:JOHANNESSEN, LORI KARINA (ATC, LAT)
Entity type:Individual
Prefix:MISS
First Name:LORI
Middle Name:KARINA
Last Name:JOHANNESSEN
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 SHELBURNE ST
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02745-3036
Mailing Address - Country:US
Mailing Address - Phone:508-998-0594
Mailing Address - Fax:
Practice Address - Street 1:101 PAGE ST
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-3464
Practice Address - Country:US
Practice Address - Phone:508-971-5155
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA14662255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer