Provider Demographics
NPI:1104874692
Name:TERESA B JOHNSTON
Entity type:Organization
Organization Name:TERESA B JOHNSTON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RODRIGO
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-776-3247
Mailing Address - Street 1:450 JEFFERSON LN
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:TN
Mailing Address - Zip Code:37716-5741
Mailing Address - Country:US
Mailing Address - Phone:865-776-3247
Mailing Address - Fax:865-577-8147
Practice Address - Street 1:4011 CHAPMAN HWY
Practice Address - Street 2:SUITE J
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-4267
Practice Address - Country:US
Practice Address - Phone:865-573-6458
Practice Address - Fax:865-577-8147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5532081OtherAETNA PPO PROVIDER ID
TN3654750Medicaid
TN960130OtherAETNA PROVIDER ID HMO
TN3654750Medicaid
TN960130OtherAETNA PROVIDER ID HMO