Provider Demographics
NPI:1194787952
Name:JOHANSEN, SANDRA LYNN (MS, ATC)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:LYNN
Last Name:JOHANSEN
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:SANDY
Other - Middle Name:
Other - Last Name:JOHANSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2603 ELIM AVE
Mailing Address - Street 2:
Mailing Address - City:ZION
Mailing Address - State:IL
Mailing Address - Zip Code:60099-2611
Mailing Address - Country:US
Mailing Address - Phone:184-746-3496
Mailing Address - Fax:847-599-4300
Practice Address - Street 1:34090 ALMOND RD
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-5310
Practice Address - Country:US
Practice Address - Phone:184-759-9441
Practice Address - Fax:847-599-4300
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other