Provider Demographics
NPI:1982050605
Name:JOHNSON, PATRICIA
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 MILLERSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSON
Mailing Address - State:KY
Mailing Address - Zip Code:42726-8126
Mailing Address - Country:US
Mailing Address - Phone:270-242-7461
Mailing Address - Fax:
Practice Address - Street 1:1360 MILLERSTOWN RD
Practice Address - Street 2:
Practice Address - City:CLARKSON
Practice Address - State:KY
Practice Address - Zip Code:42726-8126
Practice Address - Country:US
Practice Address - Phone:270-242-7461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY000038608222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist