Provider Demographics
NPI:1154679504
Name:JOHNSON, HEATHER CHRISTINE (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:CHRISTINE
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 1:9231 16TH AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-2305
Mailing Address - Country:US
Mailing Address - Phone:612-414-5825
Mailing Address - Fax:
Practice Address - Street 1:445 GALTIER ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55103-2358
Practice Address - Country:US
Practice Address - Phone:651-224-1848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN201700224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant