Provider Demographics
NPI:1588725147
Name:JOHNSON, CAROL (PT)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 BIRCH HOLLOW TRL NW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-5421
Mailing Address - Country:US
Mailing Address - Phone:770-256-3649
Mailing Address - Fax:
Practice Address - Street 1:115 BIRCH HOLLOW TRL NW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-5421
Practice Address - Country:US
Practice Address - Phone:770-256-3649
Practice Address - Fax:912-550-4802
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8190225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA8190OtherPHYSICAL THERAPY LICENSE
GA10040361OtherAMERIGROUP
GA319309OtherWELLCARE
GA530349285AMedicaid