Provider Demographics
NPI:1902320856
Name:JOHNSON, MICHAEL ALAN (DPT, ATC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2618 CHERRYWOOD LN
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-5957
Mailing Address - Country:US
Mailing Address - Phone:706-414-4118
Mailing Address - Fax:
Practice Address - Street 1:500 N WASHINGTON AVE STE 107
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2759
Practice Address - Country:US
Practice Address - Phone:321-269-0800
Practice Address - Fax:321-383-0404
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL282832251X0800X
FL35132255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer