Provider Demographics
NPI:1740755578
Name:NEAL, JOHNNY (PTA)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:NEAL
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 1:11 BURGUNDY DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-1215
Mailing Address - Country:US
Mailing Address - Phone:864-991-2641
Mailing Address - Fax:
Practice Address - Street 1:850 E BUTLER RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-5842
Practice Address - Country:US
Practice Address - Phone:864-675-6421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3973225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant