Provider Demographics
NPI:1316364300
Name:JOHNSTON, TYLER
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 WOLF RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-5643
Mailing Address - Country:US
Mailing Address - Phone:708-492-1810
Mailing Address - Fax:708-492-1807
Practice Address - Street 1:10730 NALL AVE STE 200
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66211-1285
Practice Address - Country:US
Practice Address - Phone:913-574-1460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-020594225100000X
KS11-06597225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist