Provider Demographics
NPI:1740384759
Name:JOHNSON, ADAM WEBSTER (PTA)
Entity Type:Individual
Prefix:MR
First Name:ADAM
Middle Name:WEBSTER
Last Name:JOHNSON
Suffix:
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 1:500 N FAIR ST
Mailing Address - Street 2:APT A
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959
Mailing Address - Country:US
Mailing Address - Phone:618-751-2486
Mailing Address - Fax:
Practice Address - Street 1:2907 WILLIAMSON CO PARKWAY
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959
Practice Address - Country:US
Practice Address - Phone:618-998-9894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant