Provider Demographics
NPI:1518191972
Name:JOHNSON, PAMELA S (PT)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:S
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 1:1300 W BELMONT AVE
Mailing Address - Street 2:SUITE 30
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-3200
Mailing Address - Country:US
Mailing Address - Phone:773-883-5364
Mailing Address - Fax:773-883-5365
Practice Address - Street 1:1300 W BELMONT AVE
Practice Address - Street 2:SUITE 30
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3200
Practice Address - Country:US
Practice Address - Phone:773-883-5364
Practice Address - Fax:773-883-5365
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-13
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01623654OtherBLUE CROSS BLUE SHIELD OF ILLINOIS