Provider Demographics
NPI:1861618316
Name:JOHANSEN, MENDHY (LMP)
Entity type:Individual
Prefix:MRS
First Name:MENDHY
Middle Name:
Last Name:JOHANSEN
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 1:10312 120TH ST E
Mailing Address - Street 2:SUITE 9
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-2100
Mailing Address - Country:US
Mailing Address - Phone:125-346-6376
Mailing Address - Fax:125-326-7807
Practice Address - Street 1:10312 120TH ST E
Practice Address - Street 2:SUITE 9
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-2100
Practice Address - Country:US
Practice Address - Phone:125-346-6376
Practice Address - Fax:125-326-7807
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020495225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0210470OtherWORKERS COMPENSATION, L&I
WA8853343Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER