Provider Demographics
NPI:1861589723
Name:JOHNSON, MARY SUSAN (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:SUSAN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:3048 MOMENTUM PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5330
Mailing Address - Country:US
Mailing Address - Phone:262-657-0222
Mailing Address - Fax:
Practice Address - Street 1:18000 W BLUEMOUND RD STE P
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-2931
Practice Address - Country:US
Practice Address - Phone:262-879-0010
Practice Address - Fax:262-879-9781
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2015-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3796225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2002030008OtherANTHEM BCBS PROVIDER NUMBER
WI3796-024OtherSTATE OF WI PHYSICAL THERAPY LICENSE NUMBER
WI83388002OtherPTAN