Provider Demographics
NPI:1366709958
Name:JOHNSON, HEIDI LEE (LMP)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:LEE
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 1:9518 WHEELER AVE
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98332-2141
Mailing Address - Country:US
Mailing Address - Phone:360-774-1885
Mailing Address - Fax:
Practice Address - Street 1:9216 BAYSHORE DR NW
Practice Address - Street 2:SUITE 200
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8533
Practice Address - Country:US
Practice Address - Phone:360-692-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-19
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00016981225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist