Healthcare Provider Details

I. General information

NPI: 1407022064
Provider Name (Legal Business Name): RACINE E JOHNSON DPT/OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2008
Last Update Date: 10/19/2021
Certification Date: 10/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 CLIFTWOOD DR
ATLANTA GA
30328-4840
US

IV. Provider business mailing address

10216 PERIMETER PKWY # 9
CHARLOTTE NC
28216-2461
US

V. Phone/Fax

Practice location:
  • Phone: 770-613-1201
  • Fax: 912-205-3504
Mailing address:
  • Phone: 704-808-0992
  • Fax: 704-235-1973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number11610
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number6889
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: