=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386334548
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MCKENZIE PAIGE JOHNSON OTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2023
-----------------------------------------------------
Last Update Date | 05/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 123 2ND ST N,
-----------------------------------------------------
City | WAHPETON
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-642-7047
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 GALCHUTT ST
-----------------------------------------------------
City | GALCHUTT
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58075-8108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-403-4042
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------