Provider Demographics
NPI:1477702058
Name:DOLL, JOHANNA B (PT)
Entity Type:Individual
Prefix:MRS
First Name:JOHANNA
Middle Name:B
Last Name:DOLL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:JOHANNA
Other - Middle Name:B
Other - Last Name:HANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:13537 BARRETT PARKWAY DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-5899
Mailing Address - Country:US
Mailing Address - Phone:314-821-9126
Mailing Address - Fax:314-821-9142
Practice Address - Street 1:2937 S BRENTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63144-2713
Practice Address - Country:US
Practice Address - Phone:314-961-3804
Practice Address - Fax:314-961-1147
Is Sole Proprietor?:No
Enumeration Date:2008-09-18
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO102453225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO151100002Medicare PIN
MO150900002Medicare PIN