Provider Demographics
NPI:1215200027
Name:JOHNSON, ADAM (PTA)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5072 W PLANO PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-4476
Mailing Address - Country:US
Mailing Address - Phone:972-818-3888
Mailing Address - Fax:972-818-3889
Practice Address - Street 1:5072 W PLANO PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-4476
Practice Address - Country:US
Practice Address - Phone:972-818-3888
Practice Address - Fax:972-818-3889
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2066540225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2066540OtherLICENSE