Provider Demographics
NPI:1093771479
Name:JOHNSON, SHANI T (PT,DSCPT,CMPT)
Entity type:Individual
Prefix:
First Name:SHANI
Middle Name:T
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT,DSCPT,CMPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 N BRIDGE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-2405
Mailing Address - Country:US
Mailing Address - Phone:715-723-4451
Mailing Address - Fax:715-723-5712
Practice Address - Street 1:224 N BRIDGE ST
Practice Address - Street 2:SUITE B
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-2405
Practice Address - Country:US
Practice Address - Phone:715-723-4451
Practice Address - Fax:715-723-5712
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4459-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40420100Medicaid
WI40420100Medicaid