Provider Demographics
NPI:1053511535
Name:JOHNSON, ANDREA J (PT)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 E GRAY ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202
Mailing Address - Country:US
Mailing Address - Phone:502-587-9350
Mailing Address - Fax:502-587-9351
Practice Address - Street 1:210 E GRAY ST STE 807
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3927
Practice Address - Country:US
Practice Address - Phone:502-587-9350
Practice Address - Fax:502-587-9351
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11075225100000X
KY006014225100000X
IN05008248A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC11075OtherNC LICENSE NUMBER
KY006014OtherKY LICENSE NUMBER
IN05008248AOtherIN LICENSE NUMBER
KY006014OtherKY LICENSE NUMBER