Provider Demographics
NPI:1205010410
Name:JOHNSON, LORI SUE (COTA/L)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:SUE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:MS
Other - First Name:LORI
Other - Middle Name:SUE
Other - Last Name:DAVIDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1718 N FORT VALLEY RD
Mailing Address - Street 2:APT. 126
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-1290
Mailing Address - Country:US
Mailing Address - Phone:928-380-0289
Mailing Address - Fax:
Practice Address - Street 1:3150 N WINDING BROOK RD
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-0972
Practice Address - Country:US
Practice Address - Phone:928-774-7106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2514224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant