=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174473888
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BLAKE S JOHNSON DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2026
-----------------------------------------------------
Last Update Date | 02/02/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 972 W MAIN ST
-----------------------------------------------------
City | SUN PRAIRIE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53590-2039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-318-0052
-----------------------------------------------------
Fax | 608-413-0552
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 972 W MAIN ST
-----------------------------------------------------
City | SUN PRAIRIE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53590-2039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-318-0052
-----------------------------------------------------
Fax | 608-413-0552
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------