Provider Demographics
NPI:1124397773
Name:JOHNSON, KERIA (OT R/L)
Entity Type:Individual
Prefix:
First Name:KERIA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OT R/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 N 13 TH ST
Mailing Address - Street 2:
Mailing Address - City:MONETT
Mailing Address - State:MO
Mailing Address - Zip Code:65708-3516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 N 13 TH ST
Practice Address - Street 2:
Practice Address - City:MONETT
Practice Address - State:MO
Practice Address - Zip Code:65708-3516
Practice Address - Country:US
Practice Address - Phone:417-354-0223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-27
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011024196225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist