Provider Demographics
NPI:1013139161
Name:JOHANNESEN, EVA (PT)
Entity Type:Individual
Prefix:MS
First Name:EVA
Middle Name:
Last Name:JOHANNESEN
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 1:1525 JOHN ADAMS CT
Mailing Address - Street 2:
Mailing Address - City:MAYS LANDING
Mailing Address - State:NJ
Mailing Address - Zip Code:08330-2845
Mailing Address - Country:US
Mailing Address - Phone:609-909-1862
Mailing Address - Fax:
Practice Address - Street 1:61 WEST JIMMIE LEEDS ROAD
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:NJ
Practice Address - Zip Code:08240
Practice Address - Country:US
Practice Address - Phone:609-748-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00522800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist