Provider Demographics
NPI:1750376232
Name:JOHNSON, DOUGLAS SCOTT (ATC)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:SCOTT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19326 BUCK AVE
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN
Mailing Address - State:MI
Mailing Address - Zip Code:48174-9567
Mailing Address - Country:US
Mailing Address - Phone:734-942-0776
Mailing Address - Fax:
Practice Address - Street 1:21649 GODDARD RD
Practice Address - Street 2:D386
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-4299
Practice Address - Country:US
Practice Address - Phone:734-374-3548
Practice Address - Fax:734-374-3549
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer