Provider Demographics
NPI:1568010718
Name:JOHANSEN, CHARLES TOSHIMICHI
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:TOSHIMICHI
Last Name:JOHANSEN
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 1:2166 N MOORPARK RD STE 200
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-5011
Mailing Address - Country:US
Mailing Address - Phone:805-370-1020
Mailing Address - Fax:805-370-1022
Practice Address - Street 1:2166 N MOORPARK RD STE 200
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-5011
Practice Address - Country:US
Practice Address - Phone:805-370-1020
Practice Address - Fax:805-370-1022
Is Sole Proprietor?:No
Enumeration Date:2019-08-30
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA297265225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist