Provider Demographics
NPI:1326234154
Name:JOHNSON, TANYA D (PT)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:
Other - Last Name:CANSDALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1945 SCOTTSVILLE RD
Mailing Address - Street 2:B2, PMB 356
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-3376
Mailing Address - Country:US
Mailing Address - Phone:270-842-8824
Mailing Address - Fax:270-842-7917
Practice Address - Street 1:704 W GROVE ST
Practice Address - Street 2:SUITE 5
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-4416
Practice Address - Country:US
Practice Address - Phone:870-862-1144
Practice Address - Fax:870-864-0782
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-14
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT1480225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist