Provider Demographics
NPI:1497929012
Name:JOHNSON, EBBA M (PT)
Entity Type:Individual
Prefix:
First Name:EBBA
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 74TH STREET
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143
Mailing Address - Country:US
Mailing Address - Phone:262-496-0258
Mailing Address - Fax:262-657-7784
Practice Address - Street 1:524 74TH STREET
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143
Practice Address - Country:US
Practice Address - Phone:262-496-0258
Practice Address - Fax:262-657-7784
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2940225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40167500Medicaid