Provider Demographics
NPI:1265787048
Name:JOHNSON, KAITLIN MARIE (PT)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KAITLIN
Other - Middle Name:MARIE
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-6585
Mailing Address - Fax:605-328-6512
Practice Address - Street 1:512 3RD ST NE
Practice Address - Street 2:
Practice Address - City:HARTLEY
Practice Address - State:IA
Practice Address - Zip Code:51346-1204
Practice Address - Country:US
Practice Address - Phone:712-728-2702
Practice Address - Fax:712-728-2138
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA004956225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist