Provider Demographics
NPI:1083851398
Name:JOHNSON, WILLETTA DORIS (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:WILLETTA
Middle Name:DORIS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 WESTBROOK RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-1902
Mailing Address - Country:US
Mailing Address - Phone:937-854-2117
Mailing Address - Fax:
Practice Address - Street 1:5790 DENLINGER RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45426-1838
Practice Address - Country:US
Practice Address - Phone:937-837-5581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA 00282225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist