Provider Demographics
NPI:1952332322
Name:JOHNSON, KENNETH CLARK (PT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:CLARK
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 1:8902 N MERIDIAN ST
Mailing Address - Street 2:STE 215
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-5382
Mailing Address - Country:US
Mailing Address - Phone:317-581-1890
Mailing Address - Fax:317-581-2436
Practice Address - Street 1:7855 S EMERSON AVE
Practice Address - Street 2:SUITE W
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8668
Practice Address - Country:US
Practice Address - Phone:317-581-1890
Practice Address - Fax:317-581-2436
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05005624A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist