Provider Demographics
NPI:1912233149
Name:JOHNSON, BENJAMIN (LMT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1383 LAFOND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-2437
Mailing Address - Country:US
Mailing Address - Phone:651-769-5775
Mailing Address - Fax:
Practice Address - Street 1:208 13TH AVE NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-4598
Practice Address - Country:US
Practice Address - Phone:651-769-5775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-22
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist