Provider Demographics
NPI:1902858772
Name:JOHNSON, KATHY JANE (RPT)
Entity Type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:JANE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11224 BROADVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-3723
Mailing Address - Country:US
Mailing Address - Phone:805-531-5047
Mailing Address - Fax:805-654-8149
Practice Address - Street 1:1329 E THOUSAND OAKS BLVD
Practice Address - Street 2:SUITE 118
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91362-2824
Practice Address - Country:US
Practice Address - Phone:805-551-0939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2010-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT10753225100000X
2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
P02520Medicare UPIN
WPT10753BMedicare ID - Type Unspecified