Healthcare Provider Details

I. General information

NPI: 1114979622
Provider Name (Legal Business Name): MICHAEL A. JOHNSTON PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 09/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 SILHAVY RD SUITE 121
VALPARAISO IN
46383-4484
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 219-462-0576
  • Fax: 219-462-0216
Mailing address:
  • Phone: 630-296-2222
  • Fax: 630-795-6106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4088
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT.012408
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05011255A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: