Provider Demographics
NPI:1750772398
Name:JOHANSSON, JOANN (MSPT)
Entity type:Individual
Prefix:MRS
First Name:JOANN
Middle Name:
Last Name:JOHANSSON
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S SERVICE RD
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-3316
Mailing Address - Country:US
Mailing Address - Phone:631-439-3080
Mailing Address - Fax:631-439-3139
Practice Address - Street 1:400 S SERVICE RD
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-3316
Practice Address - Country:US
Practice Address - Phone:631-439-3080
Practice Address - Fax:631-439-3139
Is Sole Proprietor?:No
Enumeration Date:2015-02-17
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019508-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist