Provider Demographics
NPI:1346611696
Name:JOHNSON, ISAIAH (LMP)
Entity type:Individual
Prefix:
First Name:ISAIAH
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21604 66TH AVE N
Mailing Address - Street 2:#A
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043
Mailing Address - Country:US
Mailing Address - Phone:425-318-0737
Mailing Address - Fax:
Practice Address - Street 1:21604 66TH AVE N
Practice Address - Street 2:#A
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043
Practice Address - Country:US
Practice Address - Phone:425-318-0737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60579169225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist