Provider Demographics
NPI:1275707945
Name:JOHNSON, STACIE MARIE (MPT)
Entity Type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1614 CHICAGO ST
Mailing Address - Street 2:
Mailing Address - City:SCHUYLER
Mailing Address - State:NE
Mailing Address - Zip Code:68661-1342
Mailing Address - Country:US
Mailing Address - Phone:402-352-5759
Mailing Address - Fax:
Practice Address - Street 1:2023 COLFAX ST
Practice Address - Street 2:
Practice Address - City:SCHUYLER
Practice Address - State:NE
Practice Address - Zip Code:68661-1025
Practice Address - Country:US
Practice Address - Phone:402-352-3977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-14
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1152225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist