Provider Demographics
NPI:1356718076
Name:JOHNSON, ISSAC
Entity type:Individual
Prefix:
First Name:ISSAC
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1517 FULLER LN
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-4211
Mailing Address - Country:US
Mailing Address - Phone:757-270-2658
Mailing Address - Fax:
Practice Address - Street 1:9160 BELVOIR WOODS PKWY
Practice Address - Street 2:
Practice Address - City:FORT BELVOIR
Practice Address - State:VA
Practice Address - Zip Code:22060-2703
Practice Address - Country:US
Practice Address - Phone:703-781-2447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-28
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119006655225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist