Provider Demographics
NPI:1235333147
Name:JOHNSON, CHARLES (PTA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:CHUCK
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:2104 FOUR WINDS DR
Mailing Address - Street 2:
Mailing Address - City:CEDAR FALLS
Mailing Address - State:IA
Mailing Address - Zip Code:50613-6435
Mailing Address - Country:US
Mailing Address - Phone:319-266-5993
Mailing Address - Fax:319-266-6142
Practice Address - Street 1:2104 FOUR WINDS DR
Practice Address - Street 2:
Practice Address - City:CEDAR FALLS
Practice Address - State:IA
Practice Address - Zip Code:50613-6435
Practice Address - Country:US
Practice Address - Phone:319-266-5993
Practice Address - Fax:319-266-6142
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00306225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant