Healthcare Provider Details

I. General information

NPI: 1003360868
Provider Name (Legal Business Name): ANNEMARIE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2016
Last Update Date: 08/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10303 QUAAL RD
BLACK HAWK SD
57718-9343
US

IV. Provider business mailing address

10303 QUAAL RD
BLACK HAWK SD
57718-9343
US

V. Phone/Fax

Practice location:
  • Phone: 605-787-5798
  • Fax:
Mailing address:
  • Phone: 605-787-5798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0145
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: