Provider Demographics
NPI:1265143093
Name:SOUSA-JOHNSON, MICHAEL (MS, LAT, ATC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SOUSA-JOHNSON
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 JUNIPER AVE
Mailing Address - Street 2:
Mailing Address - City:ALCOA
Mailing Address - State:TN
Mailing Address - Zip Code:37701-2828
Mailing Address - Country:US
Mailing Address - Phone:209-535-5176
Mailing Address - Fax:
Practice Address - Street 1:502 E LAMAR ALEXANDER PKWY
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5919
Practice Address - Country:US
Practice Address - Phone:209-535-5176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-13
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN29722255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer