Provider Demographics
NPI:1003031667
Name:JOHNSON, TABITHA
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 THOMPSON RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:41044-9074
Mailing Address - Country:US
Mailing Address - Phone:606-763-6255
Mailing Address - Fax:606-763-6245
Practice Address - Street 1:5330 LAYTHAM PIKE
Practice Address - Street 2:
Practice Address - City:MAYSLICK
Practice Address - State:KY
Practice Address - Zip Code:41055-8930
Practice Address - Country:US
Practice Address - Phone:606-763-6255
Practice Address - Fax:606-763-6245
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR3240225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist