Provider Demographics
NPI:1184997074
Name:JOHNSON, GARY WAYNE (PT, LMT)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:WAYNE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:987 NOHUNTA CT
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45231-2518
Mailing Address - Country:US
Mailing Address - Phone:513-301-7193
Mailing Address - Fax:
Practice Address - Street 1:987 NOHUNTA CT
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45231-2518
Practice Address - Country:US
Practice Address - Phone:513-301-7193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-23
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.023867225700000X
OH013568225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0779171Medicaid
OH366642Medicare Oscar/Certification