=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679194443
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHANNA FARRIS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2020
-----------------------------------------------------
Last Update Date | 12/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 155 5TH ST NE
-----------------------------------------------------
City | BARBERTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44203-3332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-615-3333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6210 CONSTANCE CIR NW
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44718-1051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-715-4619
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XP0019X
-----------------------------------------------------
Taxonomy Name | Physical Rehabilitation Occupational Therapist
-----------------------------------------------------
License Number | OT009140
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------