Provider Demographics
NPI:1750505566
Name:JOHNSON, GLEN ERIC (ATC)
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:ERIC
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:736 CAPRI CIR
Mailing Address - Street 2:
Mailing Address - City:LEWISBERRY
Mailing Address - State:PA
Mailing Address - Zip Code:17339-9584
Mailing Address - Country:US
Mailing Address - Phone:717-932-4269
Mailing Address - Fax:
Practice Address - Street 1:3280 FISSELS CHURCH RD
Practice Address - Street 2:
Practice Address - City:GLEN ROCK
Practice Address - State:PA
Practice Address - Zip Code:17327-8774
Practice Address - Country:US
Practice Address - Phone:717-235-4811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART001236A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer