Provider Demographics
NPI:1144507245
Name:JOHANSEN, LANDRIE MICHELE (PT, MPT)
Entity type:Individual
Prefix:
First Name:LANDRIE
Middle Name:MICHELE
Last Name:JOHANSEN
Suffix:
Gender:F
Credentials:PT, MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 BRIDGEWOOD DR STE 102
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-0808
Mailing Address - Country:US
Mailing Address - Phone:855-339-6378
Mailing Address - Fax:855-329-6978
Practice Address - Street 1:1100 BRIDGEWOOD DR STE 102
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-0808
Practice Address - Country:US
Practice Address - Phone:855-339-6378
Practice Address - Fax:855-329-6978
Is Sole Proprietor?:No
Enumeration Date:2011-11-03
Last Update Date:2024-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1212126225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist