Provider Demographics
NPI:1831798487
Name:JOHNSTON, OLIVIA RENEE (PT)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:RENEE
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6602 HOMER ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-3724
Mailing Address - Country:US
Mailing Address - Phone:516-232-4503
Mailing Address - Fax:
Practice Address - Street 1:26072 MERIT CIR STE 119
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-7015
Practice Address - Country:US
Practice Address - Phone:949-859-6600
Practice Address - Fax:949-859-6606
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299312225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist