Provider Demographics
NPI:1063012193
Name:JOHNSON, TIFFANY MONIQUE (PTA)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MONIQUE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 HIGH OAK
Mailing Address - Street 2:
Mailing Address - City:UNIVERSAL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78148-3705
Mailing Address - Country:US
Mailing Address - Phone:210-995-6790
Mailing Address - Fax:
Practice Address - Street 1:19138 US HIGHWAY 281 N STE 200
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4988
Practice Address - Country:US
Practice Address - Phone:210-489-7270
Practice Address - Fax:210-403-2425
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2071599225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2071599OtherTEXAS BOARD OF PHYSICAL THERAPY EXAMINERS