=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083574206
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRADLEY D JOHNSON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2025
-----------------------------------------------------
Last Update Date | 11/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2155 S STATE ROAD 46
-----------------------------------------------------
City | TERRE HAUTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47803-9781
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-618-0651
-----------------------------------------------------
Fax | 812-618-0259
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2122 YORK RD STE 300
-----------------------------------------------------
City | OAK BROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60523-1925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-812-3656
-----------------------------------------------------
Fax | 410-648-4878
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 05016228A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------