Provider Demographics
NPI:1164829685
Name:JOHNSON, TAYLOR (DPT)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5232 STONEMAN DR
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53711-7644
Mailing Address - Country:US
Mailing Address - Phone:312-640-0329
Mailing Address - Fax:
Practice Address - Street 1:1508 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-6404
Practice Address - Country:US
Practice Address - Phone:920-245-3773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.021022225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI13242-24OtherLICENSE