Provider Demographics
NPI:1821429135
Name:JOHNSON, MATTHEW JAMES (PTA)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JAMES
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 1:3106 TRADERS POINTE RD
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-8547
Mailing Address - Country:US
Mailing Address - Phone:712-329-0853
Mailing Address - Fax:
Practice Address - Street 1:2200 H ST
Practice Address - Street 2:
Practice Address - City:FAIRBURY
Practice Address - State:NE
Practice Address - Zip Code:68352-1119
Practice Address - Country:US
Practice Address - Phone:402-729-3351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-12
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1257225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant