Provider Demographics
NPI:1083914097
Name:JOHNSON, HOLLY (PT)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
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 1:2268 ROSS RD
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-9406
Mailing Address - Country:US
Mailing Address - Phone:662-808-2680
Mailing Address - Fax:662-895-0566
Practice Address - Street 1:2268 ROSS RD
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-9406
Practice Address - Country:US
Practice Address - Phone:662-808-2680
Practice Address - Fax:662-895-0566
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-25
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT 2762225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS9189701Medicaid