Provider Demographics
NPI:1184901480
Name:JOHNSON, LISA GRACE (PT)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:GRACE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:GRACE
Other - Last Name:HJALMARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:4560 SE INTERNATIONAL WAY
Mailing Address - Street 2:STE. 100
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222
Mailing Address - Country:US
Mailing Address - Phone:971-206-5200
Mailing Address - Fax:971-206-5203
Practice Address - Street 1:1601 BUTTERFIELD TRAIL
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901
Practice Address - Country:US
Practice Address - Phone:815-936-6500
Practice Address - Fax:971-206-5203
Is Sole Proprietor?:No
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012040225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist