Provider Demographics
NPI:1306095351
Name:JOHNSON, ERIC L (PTA)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7200 S LAUREL LN
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47302-8737
Mailing Address - Country:US
Mailing Address - Phone:765-288-0009
Mailing Address - Fax:
Practice Address - Street 1:1800 N WABASH AVENUE
Practice Address - Street 2:SUITE 200
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952
Practice Address - Country:US
Practice Address - Phone:765-664-5400
Practice Address - Fax:765-651-3227
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003096A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant