Provider Demographics
NPI:1407022064
Name:JOHNSON, RACINE E (DPT/OT)
Entity Type:Individual
Prefix:
First Name:RACINE
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DPT/OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10216 PERIMETER PKWY # 9
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-2461
Mailing Address - Country:US
Mailing Address - Phone:704-808-0992
Mailing Address - Fax:704-235-1973
Practice Address - Street 1:105 CLIFTWOOD DR
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-4840
Practice Address - Country:US
Practice Address - Phone:770-613-1201
Practice Address - Fax:912-205-3504
Is Sole Proprietor?:No
Enumeration Date:2008-05-05
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6889225X00000X
NC116102251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7302184Medicaid
NCQ399850281OtherMEDICARE
NC2504173Medicare PIN