Provider Demographics
NPI:1841963998
Name:JOHNSON, KYLE (DPT)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 MIDWAY RD
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1116
Mailing Address - Country:US
Mailing Address - Phone:920-257-2006
Mailing Address - Fax:
Practice Address - Street 1:9675 E ELM RD
Practice Address - Street 2:
Practice Address - City:POPLAR
Practice Address - State:WI
Practice Address - Zip Code:54864-9102
Practice Address - Country:US
Practice Address - Phone:715-364-8565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15548-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist