Provider Demographics
NPI:1407124910
Name:JOHNSON, CLARK
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 S MAIN ST STE 210
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-5768
Mailing Address - Country:US
Mailing Address - Phone:435-383-6120
Mailing Address - Fax:435-557-8003
Practice Address - Street 1:258 S MAIN ST STE 210
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-5768
Practice Address - Country:US
Practice Address - Phone:435-383-6120
Practice Address - Fax:435-557-8003
Is Sole Proprietor?:No
Enumeration Date:2011-12-12
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9307225100000X
CA38312225100000X
OR06226225100000X
MA19237225100000X
UT8030412-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist