Healthcare Provider Details

I. General information

NPI: 1457940769
Provider Name (Legal Business Name): MIKAILA ANN JOHNSON OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 01/12/2021
Certification Date: 12/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N MEDCALF ST
MONTESANO WA
98563
US

IV. Provider business mailing address

PO BOX 81
HUMPTULIPS WA
98552-0081
US

V. Phone/Fax

Practice location:
  • Phone: 360-249-2273
  • Fax: 610-925-7895
Mailing address:
  • Phone: 360-593-2269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT.OT.61129636
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: