Provider Demographics
NPI:1023327889
Name:JOHNSON, BRENDA CHARLENE (LMP)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:CHARLENE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22739 SE 29TH ST
Mailing Address - Street 2:
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98075-9532
Mailing Address - Country:US
Mailing Address - Phone:425-392-4010
Mailing Address - Fax:425-392-4011
Practice Address - Street 1:22739 SE 29TH ST
Practice Address - Street 2:
Practice Address - City:SAMMAMISH
Practice Address - State:WA
Practice Address - Zip Code:98075-9532
Practice Address - Country:US
Practice Address - Phone:425-392-4010
Practice Address - Fax:425-392-4011
Is Sole Proprietor?:No
Enumeration Date:2010-09-28
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60172762225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist