Healthcare Provider Details

I. General information

NPI: 1316254725
Provider Name (Legal Business Name): KENNETH D JOHNSON JR. PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2010
Last Update Date: 08/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7620 SOUTHERN BLVD SUITE 3
BOARDMAN OH
44512-5667
US

IV. Provider business mailing address

7620 SOUTHERN BLVD SUITE 3
BOARDMAN OH
44512-5667
US

V. Phone/Fax

Practice location:
  • Phone: 330-965-9330
  • Fax: 330-965-9308
Mailing address:
  • Phone: 330-965-9330
  • Fax: 330-965-9308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2011
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: