Healthcare Provider Details

I. General information

NPI: 1255246930
Provider Name (Legal Business Name): KAITLIN JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3915 GOLDEN VALLEY RD
GOLDEN VALLEY MN
55422-4249
US

IV. Provider business mailing address

2557 EAGLE TRACE LN
WOODBURY MN
55129-4275
US

V. Phone/Fax

Practice location:
  • Phone: 612-775-2455
  • Fax:
Mailing address:
  • Phone: 612-507-3517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number107207
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: