Provider Demographics
NPI:1972815744
Name:JOHNSON, REBECCA SUE (DPT)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:SUE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:DR
Other - First Name:REBECCA
Other - Middle Name:SUE
Other - Last Name:EVERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:11960 WESTLINE INDUSTRIAL DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3209
Mailing Address - Country:US
Mailing Address - Phone:314-819-0480
Mailing Address - Fax:314-275-7444
Practice Address - Street 1:11960 WESTLINE INDUSTRIAL DR
Practice Address - Street 2:SUITE 201
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-3209
Practice Address - Country:US
Practice Address - Phone:314-819-0480
Practice Address - Fax:314-275-7444
Is Sole Proprietor?:No
Enumeration Date:2010-07-09
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT009967225100000X
MO2012008848225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist