Healthcare Provider Details

I. General information

NPI: 1356564520
Provider Name (Legal Business Name): WAYNE A JOHANSEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

626 14TH ST
BARABOO WI
53913-1535
US

IV. Provider business mailing address

PO BOX 31
BARABOO WI
53913-0031
US

V. Phone/Fax

Practice location:
  • Phone: 608-356-2334
  • Fax: 608-356-2636
Mailing address:
  • Phone: 608-356-2334
  • Fax: 608-356-2636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number987
License Number StateWI

VIII. Authorized Official

Name: MR. WAYNE A JOHANSEN
Title or Position: OWNER/PHYSICAL THERAPIST
Credential:
Phone: 608-356-2334