MEDICARE: AMBER 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	224Z00000X	Occupational Therapy Assistant	OTA.0000655	CO

General Provider Information

NPI Number	:	1851885784
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMBER JOHNSON

Provider Business Mailing Address
First Line	:	4765 SPACEWALK WAY
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80916-2138
Country	:	US
Telephone Number	:	325-455-5992
Fax Number	:

Provider Business Practice Location Address
First Line	:	4765 SPACEWALK WAY
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80916-2138
Country	:	US
Telephone Number	:	325-455-5992
Fax Number	:

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

Provider Enumeration Date	:	06/14/2018
Last Update Date	:	06/14/2018

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