Provider Demographics
NPI:1215329024
Name:JOHNSON, THERESA (MS OTR/L)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 SWAN LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:IA
Mailing Address - Zip Code:50644-9707
Mailing Address - Country:US
Mailing Address - Phone:319-334-5155
Mailing Address - Fax:
Practice Address - Street 1:2300 SWAN LAKE BLVD
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:IA
Practice Address - Zip Code:50644-9707
Practice Address - Country:US
Practice Address - Phone:319-334-5155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-03
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01608225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist