Healthcare Provider Details

I. General information

NPI: 1750376661
Provider Name (Legal Business Name): SHIRLEY JEAN JOHNSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2499 W COTA DR
BLOOMINGTON IN
47403-4217
US

IV. Provider business mailing address

PO BOX 5635 ATTN: MARIA MITCHELL
BLOOMINGTON IN
47407
US

V. Phone/Fax

Practice location:
  • Phone: 812-337-0210
  • Fax: 812-337-0211
Mailing address:
  • Phone: 812-337-5003
  • Fax: 812-337-5010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06003063A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: