Provider Demographics
NPI:1558687640
Name:JOHNSON, MICHAEL LEWIS (MSPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEWIS
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MSPT
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 1890
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72018-1890
Mailing Address - Country:US
Mailing Address - Phone:501-778-4960
Mailing Address - Fax:501-778-4968
Practice Address - Street 1:1308 MILITARY RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-2911
Practice Address - Country:US
Practice Address - Phone:501-778-4960
Practice Address - Fax:501-778-4968
Is Sole Proprietor?:No
Enumeration Date:2010-04-14
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2275225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist