Provider Demographics
NPI:1386407864
Name:JOHNSON, BRADY NICHOLAS (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:BRADY
Middle Name:NICHOLAS
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2934 DUNLOP LN APT 312
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-1455
Mailing Address - Country:US
Mailing Address - Phone:563-940-5173
Mailing Address - Fax:
Practice Address - Street 1:6773 DESERT STORM AVE BLDG 6749
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5504
Practice Address - Country:US
Practice Address - Phone:563-940-5173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIOT-2436225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist