Provider Demographics
NPI:1841587276
Name:JOHNSON, BRETT
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 LENMAR DR
Mailing Address - Street 2:#D-102
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80905-2329
Mailing Address - Country:US
Mailing Address - Phone:218-779-5532
Mailing Address - Fax:
Practice Address - Street 1:1630 LENMAR DR
Practice Address - Street 2:#D-102
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905-2329
Practice Address - Country:US
Practice Address - Phone:218-779-5532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2079033225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant