Basic Information
| Provider Information | |||||||||
| NPI: | 1881159515 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | DEVIN | ||||||||
| MiddleName: | LUCAS | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 204 SANTA FE TRL APT 2010 | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750637153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2108899948 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12650 N BEACH ST STE 150 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762444243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174020218 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2019 | ||||||||
| LastUpdateDate: | 02/06/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1314915 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.