Provider Demographics
NPI:1871838375
Name:JOHANSEN, LAURA J (PT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:J
Last Name:JOHANSEN
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 1:1240 JESSE JEWELL PKWY SE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3862
Mailing Address - Country:US
Mailing Address - Phone:770-536-9864
Mailing Address - Fax:770-297-5023
Practice Address - Street 1:1240 JESSE JEWELL PKWY SE
Practice Address - Street 2:SUITE 500
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3862
Practice Address - Country:US
Practice Address - Phone:770-536-9864
Practice Address - Fax:770-297-5023
Is Sole Proprietor?:No
Enumeration Date:2012-12-10
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT007030225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist