Provider Demographics
NPI:1962579375
Name:JOHNSON, CLYDE W (PT, CHT)
Entity type:Individual
Prefix:MR
First Name:CLYDE
Middle Name:W
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 8TH AVE NE STE 320
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98029-5436
Mailing Address - Country:US
Mailing Address - Phone:425-462-5006
Mailing Address - Fax:425-462-5019
Practice Address - Street 1:3101 NORTHUP WAY STE 301
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-1449
Practice Address - Country:US
Practice Address - Phone:425-462-5006
Practice Address - Fax:425-462-5019
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00005729225100000X, 2251H1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1023366Medicaid