Provider Demographics
NPI:1619029337
Name:JOHNSON, SCOTT ALAN (PT)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:ALAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 MAIN ST STE 170
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80550-5561
Mailing Address - Country:US
Mailing Address - Phone:970-674-8011
Mailing Address - Fax:970-674-8051
Practice Address - Street 1:1455 MAIN ST
Practice Address - Street 2:STE 170
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-5561
Practice Address - Country:US
Practice Address - Phone:970-674-8011
Practice Address - Fax:970-674-8051
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6452225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO801620Medicare ID - Type Unspecified