Provider Demographics
NPI:1114979622
Name:JOHNSTON, MICHAEL A (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:630-795-6106
Practice Address - Street 1:71 SILHAVY RD
Practice Address - Street 2:SUITE 121
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-4484
Practice Address - Country:US
Practice Address - Phone:219-462-0576
Practice Address - Fax:219-462-0216
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4088225100000X
OHPT.012408225100000X
IN05011255A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH1692Medicaid
SCTH1692Medicaid