Provider Demographics
NPI:1316254725
Name:JOHNSON, KENNETH D JR (PT)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:D
Last Name:JOHNSON
Suffix:JR
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 1:7620 SOUTHERN BLVD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-5667
Mailing Address - Country:US
Mailing Address - Phone:330-965-9330
Mailing Address - Fax:330-965-9308
Practice Address - Street 1:7620 SOUTHERN BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-5667
Practice Address - Country:US
Practice Address - Phone:330-965-9330
Practice Address - Fax:330-965-9308
Is Sole Proprietor?:No
Enumeration Date:2010-09-07
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2011225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPT2011OtherPHYSICAL THERAPY