Provider Demographics
NPI:1194882191
Name:JOHANTGEN-BROWN, HOLLY RAE (DAOM, LAC)
Entity type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:RAE
Last Name:JOHANTGEN-BROWN
Suffix:
Gender:F
Credentials:DAOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 MAINE ST STE 11
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-3359
Mailing Address - Country:US
Mailing Address - Phone:207-809-2282
Mailing Address - Fax:207-809-2146
Practice Address - Street 1:331 MAINE ST STE 11
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-3359
Practice Address - Country:US
Practice Address - Phone:207-809-2282
Practice Address - Fax:207-809-2146
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1924171100000X
ME401171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1134676133OtherGROUP NPI