Provider Demographics
NPI:1407289622
Name:JOHANSON, BRAD A (DPT)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:A
Last Name:JOHANSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 NORTHEAST NEEXPY 8
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-3321
Mailing Address - Country:US
Mailing Address - Phone:770-500-3848
Mailing Address - Fax:
Practice Address - Street 1:2191 NORTHLAKE PKWY
Practice Address - Street 2:BUILDING 11 SUITE 31
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4166
Practice Address - Country:US
Practice Address - Phone:770-491-6004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-12
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0111682251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic