Provider Demographics
NPI:1063635548
Name:JOHNSON, BONNIE R (DT)
Entity Type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 FIELDCREST DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-4162
Mailing Address - Country:US
Mailing Address - Phone:815-397-3345
Mailing Address - Fax:815-229-9846
Practice Address - Street 1:1006 FIELDCREST DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-4162
Practice Address - Country:US
Practice Address - Phone:815-397-3345
Practice Address - Fax:815-229-9846
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYBJ36560400P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist