Provider Demographics
NPI:1972100436
Name:JOHNSON, REBECCA A (OTR/L)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
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 1:2032 W FARRAGUT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-1269
Mailing Address - Country:US
Mailing Address - Phone:920-470-1194
Mailing Address - Fax:
Practice Address - Street 1:425 DAVIS ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4729
Practice Address - Country:US
Practice Address - Phone:847-492-7713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-07
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.008175225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL056.008175OtherSTATE OT LICENSE