Provider Demographics
NPI:1154098358
Name:JOHNSON, AUBRY R (PT, DPT)
Entity Type:Individual
Prefix:
First Name:AUBRY
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 E TERRA COTTA AVE STE 244
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-3655
Mailing Address - Country:US
Mailing Address - Phone:815-354-8200
Mailing Address - Fax:224-678-0036
Practice Address - Street 1:820 E TERRA COTTA AVE STE 244
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-3655
Practice Address - Country:US
Practice Address - Phone:815-354-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14675-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist