Provider Demographics
NPI:1720142185
Name:JOHNSON, KENNETH RALPH (PT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:RALPH
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 1:2017 ESSEX ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-2512
Mailing Address - Country:US
Mailing Address - Phone:510-845-7131
Mailing Address - Fax:
Practice Address - Street 1:200 MUIR RD
Practice Address - Street 2:HACIENDA BUILDING
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-4614
Practice Address - Country:US
Practice Address - Phone:925-372-3379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA116182251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic