MEDICARE: SUSAN 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	04155	OH
2	225200000X	Physical Therapy Assistant	5240	NC

General Provider Information

NPI Number	:	1417152109
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN JOHNSON PTA

Provider Business Mailing Address
First Line	:	220 CHERRYLAUREL DR
Second Line	:
City	:	YOUNGSVILLE
State	:	NC
Zip	:	27596-7133
Country	:	US
Telephone Number	:	567-203-1971
Fax Number	:

Provider Business Practice Location Address
First Line	:	3420 HOLLOWAY ST
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27703-3522
Country	:	US
Telephone Number	:	919-596-9464
Fax Number	:

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

Provider Enumeration Date	:	06/20/2007
Last Update Date	:	09/28/2015

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