Provider Demographics
NPI:1194010637
Name:JOHNSON, KEVIN STEWART (DPT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:STEWART
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-2301
Mailing Address - Country:US
Mailing Address - Phone:507-451-7888
Mailing Address - Fax:507-451-3322
Practice Address - Street 1:123 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-2301
Practice Address - Country:US
Practice Address - Phone:507-451-7888
Practice Address - Fax:507-451-3322
Is Sole Proprietor?:No
Enumeration Date:2011-06-13
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8693225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist