Provider Demographics
NPI:1053402842
Name:JOHNSON, VIRGINIA (RPT)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:VIRGINIA
Other - Middle Name:
Other - Last Name:BERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24615 PRIMROSE LN
Mailing Address - Street 2:
Mailing Address - City:LINDSTROM
Mailing Address - State:MN
Mailing Address - Zip Code:55045-9018
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24615 PRIMROSE LN
Practice Address - Street 2:
Practice Address - City:LINDSTROM
Practice Address - State:MN
Practice Address - Zip Code:55045-9018
Practice Address - Country:US
Practice Address - Phone:763-689-5385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN611225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6402665OtherMEDICA
MN7B190JOOtherBCBS
MNHP45781OtherHEALTH PARTNERS
MN246533Medicare ID - Type UnspecifiedHDR