Provider Demographics
NPI:1417075821
Name:JOHNSON, THERESA B (PTA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:B
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 1:5203 KIMMERIDGE LOOP
Mailing Address - Street 2:
Mailing Address - City:MOSELEY
Mailing Address - State:VA
Mailing Address - Zip Code:23120-1593
Mailing Address - Country:US
Mailing Address - Phone:804-739-3207
Mailing Address - Fax:
Practice Address - Street 1:46 DIAMOND DR
Practice Address - Street 2:DINWIDIE HEALTH AND REHAB CTR
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-7495
Practice Address - Country:US
Practice Address - Phone:804-861-1324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306602738225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2306602738OtherPTA