Provider Demographics
NPI:1285113860
Name:JOHNSON, GREGORY GRIFFIN (COTA)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:GRIFFIN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6043 HWY 72 W
Mailing Address - Street 2:
Mailing Address - City:CUERO
Mailing Address - State:TX
Mailing Address - Zip Code:77954-6151
Mailing Address - Country:US
Mailing Address - Phone:361-799-9130
Mailing Address - Fax:
Practice Address - Street 1:1310 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CUERO
Practice Address - State:TX
Practice Address - Zip Code:77954-2133
Practice Address - Country:US
Practice Address - Phone:361-275-9133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX208767224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant