Provider Demographics
NPI:1265665897
Name:BRANCH, JOHANNA LEA (PTA)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:LEA
Last Name:BRANCH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5503 ORANGE VALLEY COURT
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813
Mailing Address - Country:US
Mailing Address - Phone:863-644-1707
Mailing Address - Fax:
Practice Address - Street 1:4240 LAKELAND HIGHLANDS RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813
Practice Address - Country:US
Practice Address - Phone:863-607-5948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-31
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA18857225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant