Provider Demographics
NPI:1669525150
Name:JOHNSON, MITCHELL VAN (PT)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:VAN
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 1:2319 HIGHWAY 145
Mailing Address - Street 2:
Mailing Address - City:SALTILLO
Mailing Address - State:MS
Mailing Address - Zip Code:38866-9199
Mailing Address - Country:US
Mailing Address - Phone:662-869-9970
Mailing Address - Fax:662-869-9980
Practice Address - Street 1:2319 HIGHWAY 145
Practice Address - Street 2:
Practice Address - City:SALTILLO
Practice Address - State:MS
Practice Address - Zip Code:38866-9199
Practice Address - Country:US
Practice Address - Phone:662-869-9970
Practice Address - Fax:662-869-9980
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3345225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03501321Medicaid
MS412157378OtherHEALTHLINK, UHC, TRICARE
MS650000293Medicare Oscar/Certification