Provider Demographics
NPI:1891902433
Name:JOHNSON, TRACY LYNNE (PTA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNNE
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 1:887 LINCOLN DR
Mailing Address - Street 2:
Mailing Address - City:CONNEAUT
Mailing Address - State:OH
Mailing Address - Zip Code:44030-2135
Mailing Address - Country:US
Mailing Address - Phone:316-708-4550
Mailing Address - Fax:
Practice Address - Street 1:887 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:CONNEAUT
Practice Address - State:OH
Practice Address - Zip Code:44030-2135
Practice Address - Country:US
Practice Address - Phone:214-418-4143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2033587225200000X
OHPTA005624225200000X
WVCP014960A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant