Provider Demographics
NPI:1154014702
Name:JOHNSON, LEDELL JR
Entity type:Individual
Prefix:
First Name:LEDELL
Middle Name:
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8855 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32583-8383
Mailing Address - Country:US
Mailing Address - Phone:850-602-2519
Mailing Address - Fax:
Practice Address - Street 1:8855 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32583-8383
Practice Address - Country:US
Practice Address - Phone:185-060-2251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA26405225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant