Provider Demographics
NPI:1285905588
Name:JOHNSON, KELLY B (OT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:B
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 BRIGHTON RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH MTG
Mailing Address - State:PA
Mailing Address - Zip Code:19462
Mailing Address - Country:US
Mailing Address - Phone:609-332-7485
Mailing Address - Fax:
Practice Address - Street 1:110 W WISSAHICKON AVE
Practice Address - Street 2:
Practice Address - City:FLOURTOWN
Practice Address - State:PA
Practice Address - Zip Code:19031-1898
Practice Address - Country:US
Practice Address - Phone:215-248-7864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-18
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC008294225X00000X
NJ46TR0036090225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist