Provider Demographics
NPI:1386375558
Name:JOHNSON, TRACY (DPT)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:GUS
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT
Mailing Address - Street 1:209 KIRKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98033-6503
Mailing Address - Country:US
Mailing Address - Phone:425-629-3502
Mailing Address - Fax:425-629-3517
Practice Address - Street 1:5301 LONGLEY LN UNIT C
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-1805
Practice Address - Country:US
Practice Address - Phone:916-905-6378
Practice Address - Fax:916-672-0114
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT61311447225100000X
CA304342225100000X
NV6518225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist