Provider Demographics
NPI:1093841645
Name:JOHNSON, CAROL MARIE (OTR L)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:MS
Other - First Name:CAROL
Other - Middle Name:MARIE
Other - Last Name:SEIFERT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR L
Mailing Address - Street 1:12611 ORCHARD ROAD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305
Mailing Address - Country:US
Mailing Address - Phone:952-935-5043
Mailing Address - Fax:
Practice Address - Street 1:5500 OPPORTUNITY COURT
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9020
Practice Address - Country:US
Practice Address - Phone:952-930-4267
Practice Address - Fax:952-950-4279
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN100097225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist