Provider Demographics
NPI:1740486950
Name:JOHNSON, LUCAS W (PT, DPT, SCS)
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:W
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT, DPT, SCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:437 RHODE ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23508-2141
Mailing Address - Country:US
Mailing Address - Phone:703-216-4290
Mailing Address - Fax:
Practice Address - Street 1:6330 NEWTOWN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-4802
Practice Address - Country:US
Practice Address - Phone:757-466-4401
Practice Address - Fax:757-466-4404
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23052050652251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic