Provider Demographics
NPI:1912493941
Name:JOHNSON, COLLIN J (PT)
Entity Type:Individual
Prefix:
First Name:COLLIN
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1054 US HIGHWAY 56
Mailing Address - Street 2:
Mailing Address - City:COUNCIL GROVE
Mailing Address - State:KS
Mailing Address - Zip Code:66846-8704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1350 41ST AVE STE 100
Practice Address - Street 2:
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010-3934
Practice Address - Country:US
Practice Address - Phone:831-706-2085
Practice Address - Fax:831-417-3799
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT294776225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist