Provider Demographics
NPI:1609440361
Name:JOHNCOLA, MICHAEL G JR (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:JOHNCOLA
Suffix:JR
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:711 W 40TH ST STE 170
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-2147
Practice Address - Country:US
Practice Address - Phone:667-600-4560
Practice Address - Fax:667-228-6002
Is Sole Proprietor?:No
Enumeration Date:2021-05-18
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT029668225100000X
MD225100000X
NJ40QA02065600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist