Basic Information
| Provider Information | |||||||||
| NPI: | 1962579375 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | CLYDE | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT, CHT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 510 8TH AVE NE STE 320 | ||||||||
| Address2: | |||||||||
| City: | ISSAQUAH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980295436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254625006 | ||||||||
| FaxNumber: | 4254625019 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 112TH AVE NE STE C260 | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254625006 | ||||||||
| FaxNumber: | 4254625019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 09/12/2019 | ||||||||
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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 | PT00005729 | WA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251H1200X | PT00005729 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Hand |
ID Information
| ID | Type | State | Issuer | Description | 1023366 | 05 | WA | MEDICAID |