Provider Demographics
NPI:1891737755
Name:JOHNSON, DEVIN J (MPT)
Entity Type:Individual
Prefix:MR
First Name:DEVIN
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5429
Mailing Address - Country:US
Mailing Address - Phone:608-782-7300
Mailing Address - Fax:
Practice Address - Street 1:516 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:DECORAH
Practice Address - State:IA
Practice Address - Zip Code:52101-2720
Practice Address - Country:US
Practice Address - Phone:563-382-4770
Practice Address - Fax:563-382-4785
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA030972251G0304X, 2251S0007X, 2251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN36G94JOOtherBLUE CROSS BLUE SHEILD
MN36G94JOOtherBLUE PLUS
IA34706OtherBLUE CROSS BLUE SHEILD
IA421470451OtherMAYO
IAI10017Medicare ID - Type Unspecified