Provider Demographics
NPI:1326132952
Name:JOHNSON, CAROL FRUGE (PT CLT)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:FRUGE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 W TRAVIS ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624
Mailing Address - Country:US
Mailing Address - Phone:830-997-3781
Mailing Address - Fax:830-997-3786
Practice Address - Street 1:1102 W TRAVIS ST
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624
Practice Address - Country:US
Practice Address - Phone:830-997-3781
Practice Address - Fax:830-997-3786
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1030385225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8B1734Medicare UPIN
TX00402TMedicare ID - Type Unspecified