Provider Demographics
NPI:1619963766
Name:JOHNSON, LORI L (PT, CLT)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT, CLT
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:L
Other - Last Name:JORGENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1720 S CLIFF AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-2129
Mailing Address - Country:US
Mailing Address - Phone:605-334-5630
Mailing Address - Fax:605-332-5327
Practice Address - Street 1:1720 S CLIFF AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-2129
Practice Address - Country:US
Practice Address - Phone:605-334-5630
Practice Address - Fax:605-332-5327
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1157225100000X
IA03352225100000X
MN6924225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD244T0JOOtherBLUE CROSS BLUE SHIELD MN
SD5833743Medicaid
SD5833744Medicaid
SD64-02620OtherMEDICA
SDPT1157OtherDAKOTACARE
SD4994827OtherBLUE CROSS BLUE SHIELD SD
SD4996128OtherBLUE CROSS BLUE SHEILD SD
SD596287OtherARAZ
SD64-04051OtherMEDICA
SD5833740Medicaid
SD64-03738OtherMEDICA
SD64-05327OtherMEDICA
SD20874OtherSIOUX VALLEY HEALTH PLAN
SD4997067OtherBLUE CROSS BLUE SHIELD SD
SD5833742Medicaid