Provider Demographics
NPI:1649484882
Name:JOHNSON, CAROL L
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:L
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 1:518 S HARVEY AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-4715
Mailing Address - Country:US
Mailing Address - Phone:815-232-5233
Mailing Address - Fax:
Practice Address - Street 1:245 W EXCHANGE ST STE 4
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-1495
Practice Address - Country:US
Practice Address - Phone:815-895-9227
Practice Address - Fax:815-895-2971
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist