Provider Demographics
NPI:1184203010
Name:JOHNSON'S FUNCTIONAL VILLAGE, LLC
Entity Type:Organization
Organization Name:JOHNSON'S FUNCTIONAL VILLAGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATTIA-NYDE
Authorized Official - Middle Name:CHAMPAGNE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:256-299-5380
Mailing Address - Street 1:8000 MADISON BLVD STE D102-208
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-2031
Mailing Address - Country:US
Mailing Address - Phone:256-299-5380
Mailing Address - Fax:256-464-3045
Practice Address - Street 1:8000 MADISON BLVD STE D102-208
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-2031
Practice Address - Country:US
Practice Address - Phone:256-299-5380
Practice Address - Fax:256-464-3045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1225481781Medicaid