Provider Demographics
NPI:1700175072
Name:JOHNSON, MARILYN ELIZABETH (PTA)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:ELIZABETH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MARILYN
Other - Middle Name:ELIZABETH
Other - Last Name:VAN DE BOGART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1315 LISBON STREET
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-2223
Mailing Address - Country:US
Mailing Address - Phone:305-774-9183
Mailing Address - Fax:305-774-9183
Practice Address - Street 1:2525 SW 75 AVENUE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155
Practice Address - Country:US
Practice Address - Phone:305-260-1842
Practice Address - Fax:304-267-1841
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA000333225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant