Provider Demographics
NPI:1881716660
Name:JOHNSON, LORI WALLACE (LMP LMT)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:WALLACE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMP LMT
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:ORIENE
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4460 RIORDAN HILL DRIVE
Mailing Address - Street 2:
Mailing Address - City:HOOD RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97031
Mailing Address - Country:US
Mailing Address - Phone:541-490-7711
Mailing Address - Fax:
Practice Address - Street 1:410 E JEWETT BLVD
Practice Address - Street 2:
Practice Address - City:WHITE SOLMON
Practice Address - State:WA
Practice Address - Zip Code:98672
Practice Address - Country:US
Practice Address - Phone:509-493-4000
Practice Address - Fax:509-493-1462
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00019304225700000X
OR11019225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
33752OtherAMERICAN WHOLE HEALTH NET