Provider Demographics
NPI:1669644753
Name:JOHANNSEN, JULIE (PT)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:JOHANNSEN
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 1:500 CROSS ST
Mailing Address - Street 2:
Mailing Address - City:BIG STONE CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57216-8237
Mailing Address - Country:US
Mailing Address - Phone:605-541-1140
Mailing Address - Fax:605-541-0109
Practice Address - Street 1:2440 BRIDGE AVE STE 300
Practice Address - Street 2:
Practice Address - City:ALBERT LEA
Practice Address - State:MN
Practice Address - Zip Code:56007-2098
Practice Address - Country:US
Practice Address - Phone:507-552-0022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-28
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7547225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN683227000Medicaid