Provider Demographics
NPI:1740626035
Name:JOHNSON, GAYLE A (PTA)
Entity type:Individual
Prefix:
First Name:GAYLE
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 OLD OAK DR
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44410-1122
Mailing Address - Country:US
Mailing Address - Phone:330-638-1920
Mailing Address - Fax:
Practice Address - Street 1:260 OLD OAK DR
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:OH
Practice Address - Zip Code:44410-1122
Practice Address - Country:US
Practice Address - Phone:330-638-1920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-14
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA00854225200000X
PATE001386L225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant