Provider Demographics
NPI:1144778234
Name:JOHNSTON, CHARLES MICHAEL (PT)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MICHAEL
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 1:3710 TERILYNN DR
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-1027
Mailing Address - Country:US
Mailing Address - Phone:903-297-5920
Mailing Address - Fax:
Practice Address - Street 1:100 E FERGUSON ST
Practice Address - Street 2:SUITE 1204
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-5759
Practice Address - Country:US
Practice Address - Phone:903-509-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-17
Last Update Date:2016-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1115228225100000X, 2251G0304X, 2251P0200X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic