Basic Information
| Provider Information | |||||||||
| NPI: | 1326439654 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONGBOTHAM | ||||||||
| FirstName: | JOHANNA | ||||||||
| MiddleName: | MAY | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LMT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 96 PLAINS RD | ||||||||
| Address2: | |||||||||
| City: | NEW PALTZ | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125612732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452552188 | ||||||||
| FaxNumber: | 8452552186 | ||||||||
| Practice Location | |||||||||
| Address1: | 96 PLAINS RD | ||||||||
| Address2: | |||||||||
| City: | NEW PALTZ | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125612732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452552188 | ||||||||
| FaxNumber: | 8452552186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2015 | ||||||||
| LastUpdateDate: | 02/09/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | 016607-1 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.