Provider Demographics
NPI:1114258829
Name:JOHNSON, SANDY C (LMT, MMP)
Entity type:Individual
Prefix:
First Name:SANDY
Middle Name:C
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10014 JOHN RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78015-4739
Mailing Address - Country:US
Mailing Address - Phone:830-816-2621
Mailing Address - Fax:830-816-2621
Practice Address - Street 1:10014 JOHNS RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78015-4739
Practice Address - Country:US
Practice Address - Phone:830-816-2621
Practice Address - Fax:830-816-2621
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-19
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT108963225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist