Provider Demographics
NPI:1962905620
Name:JOHNSON, BROOKE NICOLE (OT)
Entity type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:NICOLE
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 1:944 W KAWAILANI ST
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-3218
Mailing Address - Country:US
Mailing Address - Phone:808-930-9158
Mailing Address - Fax:808-930-9167
Practice Address - Street 1:944 W KAWAILANI ST
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-3218
Practice Address - Country:US
Practice Address - Phone:808-959-9151
Practice Address - Fax:808-930-9167
Is Sole Proprietor?:No
Enumeration Date:2018-03-08
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1658225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist