Provider Demographics
NPI:1194410100
Name:JOHNSON, WYATT RICHARD (LMT)
Entity type:Individual
Prefix:
First Name:WYATT
Middle Name:RICHARD
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 1:2861 N DOWNER AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-3756
Mailing Address - Country:US
Mailing Address - Phone:319-333-4875
Mailing Address - Fax:
Practice Address - Street 1:5261 N PORT WASHINGTON RD STE 101
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53217-4903
Practice Address - Country:US
Practice Address - Phone:414-332-6001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-06
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15697-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist