MEDICARE: ORIGINAL DESIGN THERAPY LLC

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1902772981
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORIGINAL DESIGN THERAPY LLC

Provider Business Mailing Address
First Line	:	1715 REDTAIL HAWK
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73003-3190
Country	:	US
Telephone Number	:	405-315-3487
Fax Number	:

Provider Business Practice Location Address
First Line	:	1715 REDTAIL HAWK
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73003-3190
Country	:	US
Telephone Number	:	405-315-3487
Fax Number	:

Authorized Official
Title or Position	:	OWNER/THERAPIST
Name	:	KRISTINE T JOHNSON
Credential	:
Telephone Number	:	405-315-3487

Provider Enumeration Date	:	10/15/2025
Last Update Date	:	10/15/2025

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