Provider Demographics
NPI:1366111510
Name:JOHNSON, ANNA (CTRS)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2063 EXCALIBUR LN
Mailing Address - Street 2:
Mailing Address - City:NORTH MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56003-4422
Mailing Address - Country:US
Mailing Address - Phone:507-508-9111
Mailing Address - Fax:
Practice Address - Street 1:2063 EXCALIBUR LN
Practice Address - Street 2:
Practice Address - City:NORTH MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56003-4422
Practice Address - Country:US
Practice Address - Phone:507-508-9111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-10
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN62353225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist