Provider Demographics
NPI:1265808414
Name:JOHNSON, SALLY (BS, PTA)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:BS, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 STATE HIGHWAY M35
Mailing Address - Street 2:
Mailing Address - City:NEGAUNEE
Mailing Address - State:MI
Mailing Address - Zip Code:49866-9544
Mailing Address - Country:US
Mailing Address - Phone:906-202-0893
Mailing Address - Fax:
Practice Address - Street 1:1001 M 28 E STE 8
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-9322
Practice Address - Country:US
Practice Address - Phone:906-273-1525
Practice Address - Fax:906-273-1535
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502004682225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant