Provider Demographics
NPI:1962168948
Name:JOHNSON, GABRIEL ADAM (PT, DPT)
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:ADAM
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21391 N LAKE PLEASANT PKWY STE 1810
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-2000
Mailing Address - Country:US
Mailing Address - Phone:623-334-8767
Mailing Address - Fax:623-566-5993
Practice Address - Street 1:21391 N LAKE PLEASANT PKWY STE 1810
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-2000
Practice Address - Country:US
Practice Address - Phone:623-334-8767
Practice Address - Fax:623-566-5993
Is Sole Proprietor?:No
Enumeration Date:2021-11-13
Last Update Date:2021-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist