Provider Demographics
NPI:1104241264
Name:JOHNSON, AMY
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 OVERLOOK RIDGE TER
Mailing Address - Street 2:APARTMENT 222
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-1167
Mailing Address - Country:US
Mailing Address - Phone:781-864-6062
Mailing Address - Fax:
Practice Address - Street 1:19 OVERLOOK RIDGE TER
Practice Address - Street 2:APARTMENT 222
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-1167
Practice Address - Country:US
Practice Address - Phone:781-864-6062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-26
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10572225X00000X
NY018553-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist