MEDICARE: MRS. SUSAN MARIE JOHNSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	31002577A	IN

General Provider Information

NPI Number	:	1770871915
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUSAN MARIE JOHNSON

Provider Business Mailing Address
First Line	:	7447 DENTON CIR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46256-2215
Country	:	US
Telephone Number	:	317-585-8654
Fax Number	:

Provider Business Practice Location Address
First Line	:	7447 DENTON CIR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46256-2215
Country	:	US
Telephone Number	:	317-585-8654
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2011
Last Update Date	:	07/20/2011

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