Provider Demographics
NPI:1255685723
Name:JOHNSON, MICHAEL (DPT, OCS, CSCS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPT, OCS, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 16573
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-0983
Mailing Address - Country:US
Mailing Address - Phone:860-422-0878
Mailing Address - Fax:
Practice Address - Street 1:20 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-7048
Practice Address - Country:US
Practice Address - Phone:203-561-7714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-05
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT96032251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports