Provider Demographics
NPI:1568557189
Name:JOHNSON, BRIDGET L (PT OCS)
Entity Type:Individual
Prefix:MRS
First Name:BRIDGET
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 MELUGINS GROVE ROAD
Mailing Address - Street 2:
Mailing Address - City:STEWARD
Mailing Address - State:IL
Mailing Address - Zip Code:60553
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:404 W BLACKHAWK DRIVE
Practice Address - Street 2:SUITE 1U
Practice Address - City:BYRON
Practice Address - State:IL
Practice Address - Zip Code:61010
Practice Address - Country:US
Practice Address - Phone:815-234-5561
Practice Address - Fax:815-234-5870
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070011438225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist