Provider Demographics
NPI:1962058784
Name:JOHNSON, PATRICE (LMT)
Entity type:Individual
Prefix:
First Name:PATRICE
Middle Name:
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 1:4019 MOUNT DAY CT
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-8279
Mailing Address - Country:US
Mailing Address - Phone:415-609-9635
Mailing Address - Fax:
Practice Address - Street 1:6460 HOLLIS ST STE C
Practice Address - Street 2:
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-1473
Practice Address - Country:US
Practice Address - Phone:415-968-1705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA76948225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist