Provider Demographics
NPI:1174773477
Name:JOHNSON, MARYANNE YAEGER (DPT)
Entity type:Individual
Prefix:
First Name:MARYANNE
Middle Name:YAEGER
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 HYDE PARK AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:MA
Mailing Address - Zip Code:02136-2819
Mailing Address - Country:US
Mailing Address - Phone:617-874-2225
Mailing Address - Fax:
Practice Address - Street 1:1234 HYDE PARK AVE STE 204
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:MA
Practice Address - Zip Code:02136-2819
Practice Address - Country:US
Practice Address - Phone:617-874-2225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18382225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist