Healthcare Provider Details

I. General information

NPI: 1962579375
Provider Name (Legal Business Name): CLYDE W JOHNSON PT, CHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 NORTHUP WAY STE 301
BELLEVUE WA
98004-1449
US

IV. Provider business mailing address

510 8TH AVE NE STE 320
ISSAQUAH WA
98029-5436
US

V. Phone/Fax

Practice location:
  • Phone: 425-462-5006
  • Fax: 425-462-5019
Mailing address:
  • Phone: 425-462-5006
  • Fax: 425-462-5019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT00005729
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code2251H1200X
TaxonomyHand Physical Therapist
License NumberPT00005729
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: