Provider Demographics
NPI:1902320856
Name:JOHNSON, MICHAEL ALAN (DPT, ATC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2618 CHERRYWOOD LN
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-5957
Mailing Address - Country:US
Mailing Address - Phone:706-414-4118
Mailing Address - Fax:
Practice Address - Street 1:500 N WASHINGTON AVE STE 107
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2759
Practice Address - Country:US
Practice Address - Phone:321-269-0800
Practice Address - Fax:321-383-0404
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL282832251X0800X, 225100000X
FL35132255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer