Healthcare Provider Details

I. General information

NPI: 1871263343
Provider Name (Legal Business Name): KAITLIN JOHNSON OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2021
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 WESTBROOK CMN
WESTBROOK ME
04092-2819
US

IV. Provider business mailing address

12 WESTBROOK CMN
WESTBROOK ME
04092-2819
US

V. Phone/Fax

Practice location:
  • Phone: 207-591-7210
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT4159
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: