MEDICARE: THERESA B JOHNSON PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	2306602738	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2306602738	OTHER	VA	PTA

General Provider Information

NPI Number	:	1417075821
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA B JOHNSON PTA

Provider Business Mailing Address
First Line	:	5203 KIMMERIDGE LOOP
Second Line	:
City	:	MOSELEY
State	:	VA
Zip	:	23120-1593
Country	:	US
Telephone Number	:	804-739-3207
Fax Number	:

Provider Business Practice Location Address
First Line	:	46 DIAMOND DR
Second Line	:	DINWIDIE HEALTH AND REHAB CTR
City	:	PETERSBURG
State	:	VA
Zip	:	23803-7495
Country	:	US
Telephone Number	:	804-861-1324
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	07/01/2010

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