Provider Demographics
NPI:1679856413
Name:JOHNSON, MATTHEW DANIEL (BA)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:DANIEL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:MATTHEW
Other - Middle Name:DANIEL
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:940 AVENUE 64
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105
Mailing Address - Country:US
Mailing Address - Phone:323-254-2274
Mailing Address - Fax:323-254-9087
Practice Address - Street 1:940 AVENUE 64
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105
Practice Address - Country:US
Practice Address - Phone:323-254-2274
Practice Address - Fax:323-254-9087
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-27
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner