Provider Demographics
NPI:1114015997
Name:JOHNSON, MARYANN S (PT)
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:S
Last Name: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 1:1939 MINNEHAHA AVE W STE 300
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-1033
Mailing Address - Country:US
Mailing Address - Phone:651-748-4338
Mailing Address - Fax:651-748-2892
Practice Address - Street 1:1270 NORTHLAND DR STE 175
Practice Address - Street 2:
Practice Address - City:MENDOTA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55120-1412
Practice Address - Country:US
Practice Address - Phone:651-905-9000
Practice Address - Fax:651-454-1603
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2886225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN590577000Medicaid
MN650000181Medicare ID - Type UnspecifiedPART B