Provider Demographics
NPI:1740306810
Name:JOHNSON-KLINE, SUSAN LEE (PT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEE
Last Name:JOHNSON-KLINE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:LEE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:1322 SANTA FE AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94702-1047
Mailing Address - Country:US
Mailing Address - Phone:510-525-4662
Mailing Address - Fax:
Practice Address - Street 1:1322 SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94702-1047
Practice Address - Country:US
Practice Address - Phone:510-525-4662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT10265225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics