Provider Demographics
NPI:1962255893
Name:JOHNSON, KURTIS (OTR/L)
Entity type:Individual
Prefix:
First Name:KURTIS
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2307 BEDELL RD
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14072-1201
Mailing Address - Country:US
Mailing Address - Phone:716-946-6339
Mailing Address - Fax:
Practice Address - Street 1:5285 LEWISTON RD
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:NY
Practice Address - Zip Code:14092-1942
Practice Address - Country:US
Practice Address - Phone:716-289-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027220225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist