Healthcare Provider Details

I. General information

NPI: 1538601554
Provider Name (Legal Business Name): BRIAN DAVID JOHNSON OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2016
Last Update Date: 11/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7370 CABOT CT STE 101
MELBOURNE FL
32940-8263
US

IV. Provider business mailing address

496 KIMBERLY DR
MELBOURNE FL
32940-7772
US

V. Phone/Fax

Practice location:
  • Phone: 321-622-8792
  • Fax:
Mailing address:
  • Phone: 301-661-1549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT17614
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT17614
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: