Provider Demographics
NPI:1386475416
Name:JOHNSON, DANIEL DAVID (ATC, LAT)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:DAVID
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2035 11TH AVE E UNIT 3
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-2534
Mailing Address - Country:US
Mailing Address - Phone:651-925-6115
Mailing Address - Fax:
Practice Address - Street 1:220 13TH AVE E
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-1671
Practice Address - Country:US
Practice Address - Phone:651-925-6115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-10
Last Update Date:2024-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3201-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer