Healthcare Provider Details

I. General information

NPI: 1710895875
Provider Name (Legal Business Name): TAI AMBER JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 HIGBIE LN
WEST ISLIP NY
11795-3930
US

IV. Provider business mailing address

621 N DUNTON AVE
EAST PATCHOGUE NY
11772-4945
US

V. Phone/Fax

Practice location:
  • Phone: 631-893-3340
  • Fax:
Mailing address:
  • Phone: 917-583-7884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number011788
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: