Individual
MARY SUSAN JOHNSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
P.T.
Contact information
Practice address
18000 W BLUEMOUND RD STE P, BROOKFIELD, WI 53045-2931
(262) 879-0010
(262) 879-9781
Mailing address
3048 MOMENTUM PL, CHICAGO, IL 60689-5330
(262) 657-0222
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
3796
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2002030008
ANTHEM BCBS PROVIDER NUMBER
WI
01
—
3796-024
STATE OF WI PHYSICAL THERAPY LICENSE NUMBER
WI
01
—
83388002
PTAN
WI
Enumeration date
10/10/2006
Last updated
12/05/2015
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