Provider Demographics
NPI:1699379941
Name:JOHNSON, BENJAMIN BRADLEY
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:BRADLEY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:352A E ROSEDALE AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-2068
Mailing Address - Country:US
Mailing Address - Phone:920-287-9966
Mailing Address - Fax:
Practice Address - Street 1:6233 BANKERS RD STE 12
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53403-9700
Practice Address - Country:US
Practice Address - Phone:262-771-0404
Practice Address - Fax:844-605-3317
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-27
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15022-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist