Healthcare Provider Details

I. General information

NPI: 1215662911
Provider Name (Legal Business Name): BROOKE LAUREN JOHNSON OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 CAMPUS DR
CLIVE IA
50325-6500
US

IV. Provider business mailing address

2417 71ST ST
URBANDALE IA
50322-4862
US

V. Phone/Fax

Practice location:
  • Phone: 515-381-6519
  • Fax:
Mailing address:
  • Phone: 404-862-5855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number278756
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number101624
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier278756
Identifier TypeOTHER
Identifier StateKY
Identifier IssuerKENTUCKY BOARD OF OCCUPATIONAL THERAPY
# 2
Identifier101624
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerIOWA BOARD OF OCCUPATIONAL AND PHYSICAL THERAPY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: