Provider Demographics
NPI:1851341234
Name:JOHNSON, BRADLEY T (PT)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:T
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 1:929 E MONTCLAIR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807
Mailing Address - Country:US
Mailing Address - Phone:417-888-0808
Mailing Address - Fax:417-888-0811
Practice Address - Street 1:929 E MONTCLAIR
Practice Address - Street 2:SUITE 104
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807
Practice Address - Country:US
Practice Address - Phone:417-888-0808
Practice Address - Fax:417-888-0811
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1012225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO169735OtherBCBS
MOP00011829OtherRAILROAD MEDICARE
MOP00011829OtherRAILROAD MEDICARE