Provider Demographics
NPI:1689048951
Name:JOHNSON, HAROLD HAZEN JR (PTA)
Entity Type:Individual
Prefix:MR
First Name:HAROLD
Middle Name:HAZEN
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23328 HORSE ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:LEWES
Mailing Address - State:DE
Mailing Address - Zip Code:19958-3344
Mailing Address - Country:US
Mailing Address - Phone:206-799-4031
Mailing Address - Fax:
Practice Address - Street 1:17028 CADBURY CIR.
Practice Address - Street 2:CADBURY AT LEWES
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958
Practice Address - Country:US
Practice Address - Phone:302-703-6087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-24
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ2-0000996225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant