MEDICARE: MR. LYLE FOSTER JOHNSON OTAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	0000001096	TN

General Provider Information

NPI Number	:	1831339589
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LYLE FOSTER JOHNSON OTAL

Provider Business Mailing Address
First Line	:	2657 APD 40
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37323-0696
Country	:	US
Telephone Number	:	423-339-1492
Fax Number	:	423-339-1496

Provider Business Practice Location Address
First Line	:	2657 APD 40
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37323-0696
Country	:	US
Telephone Number	:	423-339-1492
Fax Number	:	423-339-1496

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/20/2009
Last Update Date	:	02/20/2009

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