Provider Demographics
NPI:1689826554
Name:JOHNSON, FRED KENDALL (DPT)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:KENDALL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:359 SE 7TH ST
Mailing Address - Street 2:
Mailing Address - City:DANIA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33004-4403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:325 MDG 340 MAGNOLIA CIRCLE
Practice Address - Street 2:
Practice Address - City:TYNDALL AFB
Practice Address - State:FL
Practice Address - Zip Code:32403
Practice Address - Country:US
Practice Address - Phone:850-283-7019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029708225100000X
FLPT25177225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist