Healthcare Provider Details

I. General information

NPI: 1558825414
Provider Name (Legal Business Name): ELOISE JOHNSTON OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2019
Last Update Date: 02/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 FAIRMONT LN
PALM COAST FL
32137-9151
US

IV. Provider business mailing address

8 FAIRMONT LN
PALM COAST FL
32137-9151
US

V. Phone/Fax

Practice location:
  • Phone: 417-483-0589
  • Fax: 855-232-8604
Mailing address:
  • Phone: 417-483-0589
  • Fax: 855-232-8604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number13909
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: