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General NPI Number Information
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NPI Number | 1649482167
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Entity Type | Individual
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Provider Name | GWENDOLYN ANGELA JOHNSON DT
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Gender | Female
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Dates
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Enumeration Date | 05/04/2007
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Last Update Date | 02/26/2008
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Provider Practice Location Address
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Address Line | 29W410 FORESTVIEW DR
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City | WARRENVILLE
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State | IL
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Zip | 60555
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Country | US
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Telephone | 630-863-4936
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Fax | 630-791-9146
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Provider Business Mailing Address
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Address Line | PO BOX 431
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City | WARRENVILLE
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State | IL
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Zip | 60555-0431
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Country | US
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Telephone | 630-863-4936
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Fax | 630-791-9146
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 222Q00000X
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Taxonomy Name | Developmental Therapist
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License Number | GM11930903
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License Number State | IL
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