Provider Demographics
NPI:1831320498
Name:JOHNSON, STEPHANIE (PTA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
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 1:20347 TIMBERLAKE RD STE B
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-7352
Mailing Address - Country:US
Mailing Address - Phone:434-845-9053
Mailing Address - Fax:434-528-2788
Practice Address - Street 1:20347 TIMBERLAKE RD STE B
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-7352
Practice Address - Country:US
Practice Address - Phone:434-845-9053
Practice Address - Fax:434-528-2788
Is Sole Proprietor?:No
Enumeration Date:2009-07-30
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2364225200000X
VA2306604567225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant