Provider Demographics
NPI:1972556785
Name:JOHNSON, SUE (PT)
Entity type:Individual
Prefix:
First Name:SUE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2413 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-2254
Mailing Address - Country:US
Mailing Address - Phone:252-443-0808
Mailing Address - Fax:252-451-9032
Practice Address - Street 1:2413 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-2254
Practice Address - Country:US
Practice Address - Phone:252-443-0808
Practice Address - Fax:252-451-9032
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3455225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7212407Medicaid
NC195517OtherMEDCOST
NC5529094OtherAETNA
NC46447OtherBCBS
NC2504072AMedicare PIN
NC2504072CMedicare PIN
NC46447OtherBCBS
NC2504072BMedicare PIN