Provider Demographics
NPI:1548701204
Name:PUETZ, JOHANNA (LAT)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:PUETZ
Suffix:
Gender:F
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 DERBY LN
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-6322
Mailing Address - Country:US
Mailing Address - Phone:512-966-8045
Mailing Address - Fax:
Practice Address - Street 1:412 DERBY LN
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-6322
Practice Address - Country:US
Practice Address - Phone:512-966-8045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-14
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT61842255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer