Provider Demographics
NPI:1013074129
Name:JOHNSON, GAIL I R
Entity Type:Individual
Prefix:MS
First Name:GAIL
Middle Name:I R
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5121 WASHINGTON ST.
Mailing Address - Street 2:P.O. BOX 346
Mailing Address - City:BUTTE DES MORTS
Mailing Address - State:WI
Mailing Address - Zip Code:54927-0346
Mailing Address - Country:US
Mailing Address - Phone:920-540-4808
Mailing Address - Fax:
Practice Address - Street 1:5121 WASHINGTON ST.
Practice Address - Street 2:
Practice Address - City:BUTTE DES MORTS
Practice Address - State:WI
Practice Address - Zip Code:54927-0346
Practice Address - Country:US
Practice Address - Phone:920-540-4808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3701-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40294500Medicaid