Provider Demographics
NPI:1841341484
Name:LEARY JOHNSON, MEREDITH (CMT, LMT)
Entity type:Individual
Prefix:MS
First Name:MEREDITH
Middle Name:
Last Name:LEARY JOHNSON
Suffix:
Gender:F
Credentials:CMT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1539 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-2229
Mailing Address - Country:US
Mailing Address - Phone:651-470-3687
Mailing Address - Fax:
Practice Address - Street 1:1539 GRAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-2229
Practice Address - Country:US
Practice Address - Phone:651-470-3687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20030003274225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist