Provider Demographics
NPI:1265481329
Name:JOHNSTON, TERESA B (PT)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:B
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:TERESA
Other - Middle Name:
Other - Last Name:MASCARO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:450 JEFFERSON LN
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:TN
Mailing Address - Zip Code:37716-5741
Mailing Address - Country:US
Mailing Address - Phone:865-776-3247
Mailing Address - Fax:865-577-8147
Practice Address - Street 1:4011 CHAPMAN HWY
Practice Address - Street 2:SUITE J
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-4267
Practice Address - Country:US
Practice Address - Phone:865-573-6458
Practice Address - Fax:865-577-8147
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT0000001515225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3650902Medicaid
TN0140196OtherBLUECROSS/SHIELD INDV #
TN3650901Medicaid
TN3650902Medicaid