Provider Demographics
NPI:1033659818
Name:JOHNSON, ROGER D (PTA)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8814 PADIE SMT
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251-2585
Mailing Address - Country:US
Mailing Address - Phone:210-831-9281
Mailing Address - Fax:210-579-2113
Practice Address - Street 1:8814 PADIE SMT
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-2585
Practice Address - Country:US
Practice Address - Phone:210-831-9281
Practice Address - Fax:210-579-2113
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-28
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2091671225200000X
TXATP87911246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other