Provider Demographics
NPI:1417942954
Name:JOHNSON, MITZI (MPH, PT)
Entity Type:Individual
Prefix:MS
First Name:MITZI
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MPH, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5156
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34277-5156
Mailing Address - Country:US
Mailing Address - Phone:941-713-6628
Mailing Address - Fax:
Practice Address - Street 1:1925 BAHIA VISTA ST
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2204
Practice Address - Country:US
Practice Address - Phone:941-713-6628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL650144307OtherTAX IDENTIFICATION NUMBER
FLY045VOtherBCBS
FL887298800Medicaid