Basic Information
Provider Information | |||||||||
NPI: | 1841498961 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOHANNES | ||||||||
FirstName: | CHRISTOPHER | ||||||||
MiddleName: | MICHAEL | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PTA, ATC/L | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2 POMPERAUG OFFICE PARK | ||||||||
Address2: | SUITE 303 | ||||||||
City: | SOUTHBURY | ||||||||
State: | CT | ||||||||
PostalCode: | 064882288 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2032641735 | ||||||||
FaxNumber: | 2032649251 | ||||||||
Practice Location | |||||||||
Address1: | 2 POMPERAUG OFFICE PARK | ||||||||
Address2: | SUITE 303 | ||||||||
City: | SOUTHBURY | ||||||||
State: | CT | ||||||||
PostalCode: | 064882288 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2032641735 | ||||||||
FaxNumber: | 2032649251 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/10/2007 | ||||||||
LastUpdateDate: | 07/15/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 000293 | CT | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 225200000X | 1590 | CT | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |   |
No ID Information.