Healthcare Provider Details

I. General information

NPI: 1710209911
Provider Name (Legal Business Name): SHAUNNA K JOHNSON OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHAUNNA BERG OT

II. Dates (important events)

Enumeration Date: 02/16/2010
Last Update Date: 02/16/2021
Certification Date: 02/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32021 COUNTY 24 BLVD
CANNON FALLS MN
55009-5003
US

IV. Provider business mailing address

820 ROY ST
ORTONVILLE MN
56278-1138
US

V. Phone/Fax

Practice location:
  • Phone: 507-377-6285
  • Fax:
Mailing address:
  • Phone: 320-839-4271
  • Fax: 320-839-4196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number103850
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: