Provider Demographics
NPI:1831126028
Name:JOHNSON, SCOTT A (PT)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 950
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94948-0950
Mailing Address - Country:US
Mailing Address - Phone:415-898-1311
Mailing Address - Fax:415-897-0741
Practice Address - Street 1:12845 FM 2154 RD
Practice Address - Street 2:SUITE 100
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-3982
Practice Address - Country:US
Practice Address - Phone:979-696-4800
Practice Address - Fax:979-695-6947
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1137719225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1137719OtherPHYSICAL THERAPY LICENSE
TX8T1331OtherBCBS PROVIDER #
TX81-0608159OtherEIN
TX8A8108Medicare ID - Type Unspecified