Provider Demographics
NPI:1982722625
Name:JOHNSON, THEODORE J (LMP)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:TED
Other - Middle Name:J
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMP
Mailing Address - Street 1:2132 44TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-2102
Mailing Address - Country:US
Mailing Address - Phone:206-261-0160
Mailing Address - Fax:206-937-1933
Practice Address - Street 1:2132 44TH AVE SW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98116-2102
Practice Address - Country:US
Practice Address - Phone:206-261-0160
Practice Address - Fax:206-937-1933
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00010180174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist