Provider Demographics
NPI:1912410937
Name:JOHNSON, KIM (OT)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
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:PO BOX 379
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-0379
Mailing Address - Country:US
Mailing Address - Phone:708-460-9833
Mailing Address - Fax:708-460-1117
Practice Address - Street 1:5009 W 95TH ST STE A
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2401
Practice Address - Country:US
Practice Address - Phone:708-499-2622
Practice Address - Fax:708-499-9466
Is Sole Proprietor?:No
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056005552225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist