Provider Demographics
NPI:1215662911
Name:JOHNSON, BROOKE LAUREN (OTR/L)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:LAUREN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2417 71ST ST
Mailing Address - Street 2:
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50322-4862
Mailing Address - Country:US
Mailing Address - Phone:404-862-5855
Mailing Address - Fax:
Practice Address - Street 1:1401 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-6500
Practice Address - Country:US
Practice Address - Phone:515-381-6519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY278756225X00000X
IA101624225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY278756OtherKENTUCKY BOARD OF OCCUPATIONAL THERAPY
IA101624OtherIOWA BOARD OF OCCUPATIONAL AND PHYSICAL THERAPY