Provider Demographics
NPI:1093720773
Name:GARRETT-JOHNSON, BRENDA (PT)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:GARRETT-JOHNSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13786 FRONTIER CT
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-4831
Mailing Address - Country:US
Mailing Address - Phone:952-432-8677
Mailing Address - Fax:
Practice Address - Street 1:1609 COUNTY ROAD 42 W
Practice Address - Street 2:SUITE 206
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-6213
Practice Address - Country:US
Practice Address - Phone:952-891-2645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4862225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6405396OtherMEDICA-UNITED HEALTHCARE
MN017N3PHOtherBCBS OF MN
MN048192000Medicaid