MEDICARE: GWANETIA M JOHNSON PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	1960	SC

General Provider Information

NPI Number	:	1023152543
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GWANETIA M JOHNSON PTA

Provider Business Mailing Address
First Line	:	504 CAMBOUT ST
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29210-7121
Country	:	US
Telephone Number	:	803-238-8788
Fax Number	:

Provider Business Practice Location Address
First Line	:	2601 FOREST DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29204-2363
Country	:	US
Telephone Number	:	803-765-7127
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/17/2007
Last Update Date	:	07/08/2007

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