Healthcare Provider Details

I. General information

NPI: 1609164763
Provider Name (Legal Business Name): MICHELLE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2011
Last Update Date: 07/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5535 S WILLIAMSON BLVD 774
PORT ORANGE FL
32128-8311
US

IV. Provider business mailing address

810 CENTEROAK DR
KNOXVILLE TN
37920-5234
US

V. Phone/Fax

Practice location:
  • Phone: 800-330-7711
  • Fax: 866-426-2811
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT.007876
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: