Provider Demographics
NPI:1225489461
Name:JOHNSON, LYDIA (ATC)
Entity Type:Individual
Prefix:MISS
First Name:LYDIA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 VINICIO DR
Mailing Address - Street 2:
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445-3666
Mailing Address - Country:US
Mailing Address - Phone:828-545-2801
Mailing Address - Fax:843-863-7392
Practice Address - Street 1:9200 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9121
Practice Address - Country:US
Practice Address - Phone:843-863-7412
Practice Address - Fax:843-863-7392
Is Sole Proprietor?:No
Enumeration Date:2016-06-29
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAT10622255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer