Provider Demographics
NPI:1588707509
Name:JOHNSON-WENSINK, SIMONE
Entity type:Individual
Prefix:
First Name:SIMONE
Middle Name:
Last Name:JOHNSON-WENSINK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8700 BRODIE LN APT 124
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-7923
Mailing Address - Country:US
Mailing Address - Phone:512-567-6586
Mailing Address - Fax:
Practice Address - Street 1:8700 BRODIE LN APT 124
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-7923
Practice Address - Country:US
Practice Address - Phone:512-567-6586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1084598225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126129901Medicaid
TX8T6693OtherBLUE CROSS
TX021286201Medicaid