Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 1115228 | TX |
N | 2251G0304X | Physical Therapist - Geriatrics | 1115228 | TX |
N | 2251P0200X | Physical Therapist - Pediatrics | 1115228 | TX |
N | 2251X0800X | Physical Therapist - Orthopedic | 1115228 | TX |
NPI | 1144778234 |
---|---|
Provider Name | Charles Michael Johnston |
First Address | Longview, TX 75604-1027 |
Second Address | Tyler, TX 75702-5759 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/09/2016 |
Last Update Date | 17/09/2016 |