Provider Demographics
NPI:1750376661
Name:JOHNSON, SHIRLEY JEAN (PTA)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:JEAN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5635
Mailing Address - Street 2:ATTN: MARIA MITCHELL
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47407
Mailing Address - Country:US
Mailing Address - Phone:812-337-5003
Mailing Address - Fax:812-337-5010
Practice Address - Street 1:2499 W COTA DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-4217
Practice Address - Country:US
Practice Address - Phone:812-337-0210
Practice Address - Fax:812-337-0211
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003063A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2157141OtherFIRST HEALTH (CSC)