Provider Demographics
NPI:1386042612
Name:JOHNSON, BRENDA (PTA)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 EASTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78155-5134
Mailing Address - Country:US
Mailing Address - Phone:830-379-9308
Mailing Address - Fax:830-401-7901
Practice Address - Street 1:1210 EASTWOOD DR
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-5134
Practice Address - Country:US
Practice Address - Phone:830-379-9308
Practice Address - Fax:830-401-7901
Is Sole Proprietor?:No
Enumeration Date:2014-12-19
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2033355225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant