Provider Demographics
NPI:1952056723
Name:JOHNSON, LAVON (PTA)
Entity Type:Individual
Prefix:
First Name:LAVON
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 PRESIDENTIAL DR APT B
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19807-3212
Mailing Address - Country:US
Mailing Address - Phone:302-650-3960
Mailing Address - Fax:
Practice Address - Street 1:121 PRESIDENTIAL DR APT B
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19807-3212
Practice Address - Country:US
Practice Address - Phone:302-650-3960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-19
Last Update Date:2022-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ2-0000856225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty