Provider Demographics
NPI:1316233935
Name:JOHNSON, KAROLINE G (OT)
Entity type:Individual
Prefix:MRS
First Name:KAROLINE
Middle Name:G
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 1:16425 HIGHWAY 57
Mailing Address - Street 2:
Mailing Address - City:VANCLEAVE
Mailing Address - State:MS
Mailing Address - Zip Code:39565-9010
Mailing Address - Country:US
Mailing Address - Phone:228-990-2476
Mailing Address - Fax:
Practice Address - Street 1:16425 HIGHWAY 57
Practice Address - Street 2:
Practice Address - City:VANCLEAVE
Practice Address - State:MS
Practice Address - Zip Code:39565-9010
Practice Address - Country:US
Practice Address - Phone:228-990-2476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-22
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT2393225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015077Medicaid
MS1033218524OtherGROUP NPI
MS09015077Medicaid