Provider Demographics
NPI:1730194465
Name:JOHNSON, HEIDI JO (PT)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:JO
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:JO
Other - Last Name:KRAUTKRAMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:D-PT
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:1630 COMMANCHE AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-6089
Practice Address - Country:US
Practice Address - Phone:920-430-4750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10899225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100200062Medicare Oscar/Certification
WI526595Medicare Oscar/Certification
WI073550096Medicare Oscar/Certification
WI075100109Medicare Oscar/Certification
WI802100035Medicare Oscar/Certification
WI002150232Medicare Oscar/Certification
WIK400217480Medicare Oscar/Certification
WI073050055Medicare Oscar/Certification
WI330000035Medicare Oscar/Certification
WI802100035Medicare Oscar/Certification