Provider Demographics
NPI:1639660939
Name:JOHNSON, CHASE ETHAN (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:CHASE
Middle Name:ETHAN
Last Name:JOHNSON
Suffix:
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 1:1113 HIGHGATE RD
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-3825
Mailing Address - Country:US
Mailing Address - Phone:214-799-7639
Mailing Address - Fax:
Practice Address - Street 1:1301 SUMMER LEE DR
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-5452
Practice Address - Country:US
Practice Address - Phone:214-771-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1304538225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist