Provider Demographics
NPI:1821509571
Name:JOHNSON, THERESA (PTA)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1065 HOLLIS RD
Mailing Address - Street 2:
Mailing Address - City:ELLENBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28040-7764
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:518 OLD US 221 HWY
Practice Address - Street 2:
Practice Address - City:RUTHERFORDTON
Practice Address - State:NC
Practice Address - Zip Code:28139-8670
Practice Address - Country:US
Practice Address - Phone:828-748-7561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-21
Last Update Date:2017-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant