Provider Demographics
NPI:1528386240
Name:JOHNSON, COLLIN ANTHONY (DPT)
Entity Type:Individual
Prefix:
First Name:COLLIN
Middle Name:ANTHONY
Last Name:JOHNSON
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 1:1238 BEDFORD AVE
Mailing Address - Street 2:APT# 4
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-1822
Mailing Address - Country:US
Mailing Address - Phone:631-241-3983
Mailing Address - Fax:
Practice Address - Street 1:1238 BEDFORD AVE
Practice Address - Street 2:APT #4
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-1822
Practice Address - Country:US
Practice Address - Phone:631-241-3983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-05
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031114225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist