Provider Demographics
NPI:1780133140
Name:JOHNSON, REGINALD
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 NW 21ST AVE
Mailing Address - Street 2:STE 3
Mailing Address - City:CHIEFLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32626-1978
Mailing Address - Country:US
Mailing Address - Phone:386-362-9419
Mailing Address - Fax:
Practice Address - Street 1:1315 NW 21ST AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:CHIEFLAND
Practice Address - State:FL
Practice Address - Zip Code:32626-1977
Practice Address - Country:US
Practice Address - Phone:352-493-2999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-27
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTT 31971225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist