Provider Demographics
NPI:1033476734
Name:JOHNSON, SAMANTHA BROOKE (COTA)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:BROOKE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 OLD SMITHVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37110-6805
Mailing Address - Country:US
Mailing Address - Phone:931-473-8431
Mailing Address - Fax:
Practice Address - Street 1:928 OLD SMITHVILLE ROAD
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:TENNESSEE
Practice Address - Zip Code:37110
Practice Address - Country:UM
Practice Address - Phone:931-473-8431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000001904224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN621824988Medicare PIN