Provider Demographics
NPI:1619078342
Name:JOHNSON, LISA MARIE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 5TH STREET
Mailing Address - Street 2:
Mailing Address - City:PROCTOR
Mailing Address - State:MN
Mailing Address - Zip Code:55810
Mailing Address - Country:US
Mailing Address - Phone:218-349-3585
Mailing Address - Fax:715-394-2191
Practice Address - Street 1:1420 OAKES AVENUE
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880
Practice Address - Country:US
Practice Address - Phone:715-394-6355
Practice Address - Fax:715-394-2191
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1018019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant