Provider Demographics
NPI:1336317700
Name:JOHNSON, GREGORY SCOTT (PT)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:SCOTT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SHIELDS AVE
Mailing Address - Street 2:COWELL STUDENT HEALTH CENTER
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-5270
Mailing Address - Country:US
Mailing Address - Phone:530-752-2318
Mailing Address - Fax:530-752-2306
Practice Address - Street 1:1 SHIELDS AVE
Practice Address - Street 2:COWELL STUDENT HEALTH CENTER
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-5270
Practice Address - Country:US
Practice Address - Phone:530-752-2318
Practice Address - Fax:530-752-2306
Is Sole Proprietor?:No
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17250225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist