Provider Demographics
NPI:1588064307
Name:JOHANSON, CASEY
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:JOHANSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 VISTA VIEW PL
Mailing Address - Street 2:
Mailing Address - City:EAST WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98802-4048
Mailing Address - Country:US
Mailing Address - Phone:509-264-3957
Mailing Address - Fax:
Practice Address - Street 1:2623 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-3596
Practice Address - Country:US
Practice Address - Phone:509-664-7081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-28
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60481288225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist