Provider Demographics
NPI:1093260630
Name:JOHNSON, BROOKE LEIGH (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:LEIGH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 FAIR RIDGE DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2917
Mailing Address - Country:US
Mailing Address - Phone:703-865-7680
Mailing Address - Fax:
Practice Address - Street 1:4001 FAIR RIDGE DR
Practice Address - Street 2:SUITE 203
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2917
Practice Address - Country:US
Practice Address - Phone:703-865-7680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305210645225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist