Provider Demographics
NPI:1558876276
Name:JOHNSON, MARLIN
Entity Type:Individual
Prefix:
First Name:MARLIN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4714 N HABANA AVE APT 3004
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-7141
Mailing Address - Country:US
Mailing Address - Phone:813-727-0734
Mailing Address - Fax:
Practice Address - Street 1:4714 N HABANA AVE APT 3004
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7141
Practice Address - Country:US
Practice Address - Phone:813-727-0734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA27014225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant