Provider Demographics
NPI:1679583645
Name:JOHNSON, ELLIS EDWARD III (PT)
Entity Type:Individual
Prefix:MR
First Name:ELLIS
Middle Name:EDWARD
Last Name:JOHNSON
Suffix:III
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:PO BOX 392
Mailing Address - Street 2:
Mailing Address - City:WATSON
Mailing Address - State:LA
Mailing Address - Zip Code:70786
Mailing Address - Country:US
Mailing Address - Phone:225-791-7770
Mailing Address - Fax:225-791-7725
Practice Address - Street 1:35055 LA HWY 16
Practice Address - Street 2:STE 1C
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70706
Practice Address - Country:US
Practice Address - Phone:225-791-7770
Practice Address - Fax:225-791-7725
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA03226225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
5C580Medicare ID - Type Unspecified
5X707Medicare ID - Type Unspecified