Healthcare Provider Details

I. General information

NPI: 1942240692
Provider Name (Legal Business Name): DANA ELLYN JOHNSON DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 02/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 47TH AVE
ROCK ISLAND IL
61201-6964
US

IV. Provider business mailing address

2400 47TH AVE
ROCK ISLAND IL
61201-6964
US

V. Phone/Fax

Practice location:
  • Phone: 715-255-2772
  • Fax:
Mailing address:
  • Phone: 715-255-2772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number02120
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number070-018070
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number11006-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: