Provider Demographics
NPI:1346706546
Name:JOHNSON, GILISSA
Entity Type:Individual
Prefix:
First Name:GILISSA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20410 CENTURY BLVD STE 215
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20874-1187
Mailing Address - Country:US
Mailing Address - Phone:240-731-9641
Mailing Address - Fax:
Practice Address - Street 1:12825 MINNIEVILLE RD
Practice Address - Street 2:
Practice Address - City:LAKE RIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-3601
Practice Address - Country:US
Practice Address - Phone:703-971-3701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-13
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305213488225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT34397OtherPT LICENSE