Healthcare Provider Details

I. General information

NPI: 1467767277
Provider Name (Legal Business Name): LISA JOHNSON MA,OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2010
Last Update Date: 08/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E DEL MAR BLVD SUITE 112
PASADENA CA
91105-2544
US

IV. Provider business mailing address

200 E DEL MAR BLVD SUITE 112
PASADENA CA
91105-2544
US

V. Phone/Fax

Practice location:
  • Phone: 626-564-2700
  • Fax:
Mailing address:
  • Phone: 626-564-2700
  • Fax: 626-564-2770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number10309
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: