Provider Demographics
NPI:1093183485
Name:JOHNSON, DIANNE (PT)
Entity Type:Individual
Prefix:
First Name:DIANNE
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 1:2785 GULF FWY S
Mailing Address - Street 2:SUITE 125
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-4979
Mailing Address - Country:US
Mailing Address - Phone:281-535-3300
Mailing Address - Fax:281-534-3386
Practice Address - Street 1:2785 GULF FWY S
Practice Address - Street 2:SUITE 125
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-4979
Practice Address - Country:US
Practice Address - Phone:281-535-3300
Practice Address - Fax:281-534-3386
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-02
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1085165225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist