Provider Demographics
NPI:1033379474
Name:JOHNSON, MICHAEL TODD (CMT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TODD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 W GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-2415
Mailing Address - Country:US
Mailing Address - Phone:715-723-4451
Mailing Address - Fax:715-723-4451
Practice Address - Street 1:26 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-2415
Practice Address - Country:US
Practice Address - Phone:715-723-4451
Practice Address - Fax:715-723-4451
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI419148-00225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist