Healthcare Provider Details

I. General information

NPI: 1871981654
Provider Name (Legal Business Name): CHRISTINE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2015
Last Update Date: 01/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 N DALTON ST
BARTLETT TX
76511-4332
US

IV. Provider business mailing address

2801 WOODLAWN ST
TAYLOR TX
76574-5042
US

V. Phone/Fax

Practice location:
  • Phone: 254-527-3371
  • Fax:
Mailing address:
  • Phone: 512-439-9243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number206652
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: