Provider Demographics
NPI:1104951714
Name:JOHNSON, KATHLEEN M (LPT)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 N HIGHWAY 19
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63361-5217
Mailing Address - Country:US
Mailing Address - Phone:573-564-2278
Mailing Address - Fax:573-564-6182
Practice Address - Street 1:COUNTY OF MONTGOMERY SCHOOL DIST R 11
Practice Address - Street 2:418 N HIGHWAY 19
Practice Address - City:MONTGOMERY CITY
Practice Address - State:MO
Practice Address - Zip Code:63361-5217
Practice Address - Country:US
Practice Address - Phone:573-564-2278
Practice Address - Fax:573-564-6182
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO00342225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO486759319Medicaid