MEDICARE: CRYSTAL JOHNSON

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	225X00000X	Occupational Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	J525104977040	OTHER	FL	DRIVERS LICENSE

General Provider Information

NPI Number	:	1942916762
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL JOHNSON

Provider Business Mailing Address
First Line	:	2804 SPRING VISTA CT
Second Line	:
City	:	PLANT CITY
State	:	FL
Zip	:	33566-9617
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2804 SPRING VISTA CT
Second Line	:
City	:	PLANT CITY
State	:	FL
Zip	:	33566-9617
Country	:	US
Telephone Number	:	813-528-5922
Fax Number	:

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

Provider Enumeration Date	:	01/25/2023
Last Update Date	:	01/25/2023

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Directions to “ CRYSTAL JOHNSON ” Practice Location

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