Provider Demographics
NPI:1114175098
Name:JOHNSON, KENNETH LEE (PT,OT)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT,OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 48066
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-5766
Mailing Address - Country:US
Mailing Address - Phone:313-822-3464
Mailing Address - Fax:
Practice Address - Street 1:740 SAINT CLAIR ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214-3660
Practice Address - Country:US
Practice Address - Phone:313-822-3464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501001186225100000X
MI5201003272225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist