Provider Demographics
NPI:1922405679
Name:JOHNSON, SUZANNE (PT, MPT, OCS)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT, MPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:649 N 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4714
Mailing Address - Country:US
Mailing Address - Phone:909-203-3924
Mailing Address - Fax:
Practice Address - Street 1:649 N 1ST AVE
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4714
Practice Address - Country:US
Practice Address - Phone:909-203-3924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-24
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22886225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic