Provider Demographics
NPI:1043477383
Name:JOHNSON, TONYA ANNE (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:TONYA
Middle Name:ANNE
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 1:1710 RICHLAND ST
Mailing Address - Street 2:B
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2636
Mailing Address - Country:US
Mailing Address - Phone:803-253-6223
Mailing Address - Fax:803-253-6224
Practice Address - Street 1:1710 RICHLAND ST
Practice Address - Street 2:B
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2636
Practice Address - Country:US
Practice Address - Phone:803-253-6223
Practice Address - Fax:803-253-6224
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1095225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTHO374Medicaid