Provider Demographics
NPI:1699520619
Name:JOHNSON, CAROL THERESA (RADT)
Entity type:Individual
Prefix:MISS
First Name:CAROL
Middle Name:THERESA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79100 OCOTILLO DR
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-5915
Mailing Address - Country:US
Mailing Address - Phone:760-834-8418
Mailing Address - Fax:
Practice Address - Street 1:79100 OCOTILLO DR
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-5915
Practice Address - Country:US
Practice Address - Phone:760-834-8418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1523020823247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Single Specialty