Provider Demographics
NPI:1093849796
Name:JOHNSON, CRAIG ALLEN (PT)
Entity type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:ALLEN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2611 NORTHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:GOTHENBURG
Mailing Address - State:NE
Mailing Address - Zip Code:69138-1174
Mailing Address - Country:US
Mailing Address - Phone:308-537-4023
Mailing Address - Fax:
Practice Address - Street 1:910 20TH ST
Practice Address - Street 2:
Practice Address - City:GOTHENBURG
Practice Address - State:NE
Practice Address - Zip Code:69138-1237
Practice Address - Country:US
Practice Address - Phone:308-537-4023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1836225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist