Provider Demographics
NPI:1225435779
Name:JOHNSON, MICHAEL SCOT
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SCOT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7200 JACINTO AVE
Mailing Address - Street 2:UNIT 15202
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-7555
Mailing Address - Country:US
Mailing Address - Phone:920-740-7920
Mailing Address - Fax:
Practice Address - Street 1:1210 A ST
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-2327
Practice Address - Country:US
Practice Address - Phone:920-740-7920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-28
Last Update Date:2014-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5089-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant