Provider Demographics
NPI:1306122155
Name:JOHNSON, AIMEE DESIREE (LMT)
Entity type:Individual
Prefix:MRS
First Name:AIMEE
Middle Name:DESIREE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 S BARSTOW ST
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-4978
Mailing Address - Country:US
Mailing Address - Phone:715-529-3489
Mailing Address - Fax:
Practice Address - Street 1:705 S BARSTOW ST
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-4978
Practice Address - Country:US
Practice Address - Phone:715-529-3489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10374-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist