Provider Demographics
NPI:1972358208
Name:JOHNSON, KELLY ANN MARIE (MOT, OTR/L)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4506 SE 33RD CT
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-8250
Mailing Address - Country:US
Mailing Address - Phone:916-968-6320
Mailing Address - Fax:
Practice Address - Street 1:330 W POWELL BLVD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7051
Practice Address - Country:US
Practice Address - Phone:916-968-6320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR445164225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist