Provider Demographics
NPI:1447443908
Name:JOHNSON, NATHAN RICHARD (BS, DPT)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:RICHARD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:BS, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2118 W RACE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-1510
Mailing Address - Country:US
Mailing Address - Phone:312-479-1103
Mailing Address - Fax:
Practice Address - Street 1:2118 W RACE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-1510
Practice Address - Country:US
Practice Address - Phone:312-479-1103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-19
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL70015225225100000X
NE2460225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist