Provider Demographics
NPI:1174053946
Name:JOHNSON, HEATHER MARIE (DT)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 W. BRADLEY AVE.
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821
Mailing Address - Country:US
Mailing Address - Phone:217-356-9176
Mailing Address - Fax:217-356-9851
Practice Address - Street 1:1304 W BRADLEY AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-2035
Practice Address - Country:US
Practice Address - Phone:217-356-9176
Practice Address - Fax:217-356-9851
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist