Basic Information
| Provider Information | |||||||||
| NPI: | 1629721766 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MIKALYN | ||||||||
| MiddleName: | MARICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1379 N WESTERN AVE APT 3A | ||||||||
| Address2: | |||||||||
| City: | LAKE FOREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600455401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055506126 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10137 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601312548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474517590 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2022 | ||||||||
| LastUpdateDate: | 01/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.