Provider Demographics
NPI:1205318359
Name:JOHNSON, CARL ANDREW (PTA)
Entity type:Individual
Prefix:MR
First Name:CARL
Middle Name:ANDREW
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 1:405 MOODY ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:75840-3037
Mailing Address - Country:US
Mailing Address - Phone:937-679-6675
Mailing Address - Fax:
Practice Address - Street 1:420 MOODY ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:TX
Practice Address - Zip Code:75840-3036
Practice Address - Country:US
Practice Address - Phone:937-679-6675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2099140225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant