Provider Demographics
NPI:1720136245
Name:JOHNSON, REGINALD A (LPTA)
Entity Type:Individual
Prefix:MR
First Name:REGINALD
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 9TH ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39307-6508
Mailing Address - Country:US
Mailing Address - Phone:601-938-3033
Mailing Address - Fax:
Practice Address - Street 1:711 AVIGNON DR
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-5120
Practice Address - Country:US
Practice Address - Phone:601-605-6777
Practice Address - Fax:601-605-8869
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA2753225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant