Provider Demographics
NPI:1689065518
Name:JOHNSON, GARY (LAT, PT)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LAT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-2051
Mailing Address - Country:US
Mailing Address - Phone:608-225-0302
Mailing Address - Fax:
Practice Address - Street 1:1440 MONROE ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-2051
Practice Address - Country:US
Practice Address - Phone:608-225-0302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-13
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1089-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer