Provider Demographics
NPI:1609895432
Name:JOHNSON, DOUGLAS BRENT (RPT)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:BRENT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RPT
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 3070
Mailing Address - Street 2:
Mailing Address - City:SHELL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93448-3070
Mailing Address - Country:US
Mailing Address - Phone:805-439-2159
Mailing Address - Fax:805-439-2160
Practice Address - Street 1:3440 S HIGUERA ST
Practice Address - Street 2:SUITE 120
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-7393
Practice Address - Country:US
Practice Address - Phone:805-439-2159
Practice Address - Fax:805-439-2160
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT14568225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0145680Medicaid
CAPT0145680Medicaid