Provider Demographics
NPI:1235582578
Name:JOHNSTON, CAITLIN MARIE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:CAITLIN
Middle Name:MARIE
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-6250
Mailing Address - Fax:630-575-7450
Practice Address - Street 1:1155 S COLLEGE MALL RD
Practice Address - Street 2:SUITE A
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-6177
Practice Address - Country:US
Practice Address - Phone:812-558-3356
Practice Address - Fax:812-558-3377
Is Sole Proprietor?:No
Enumeration Date:2016-07-21
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31006142A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1740602861OtherGROUP NPI
IN46-4446075OtherTAX ID
ININ1872OtherMEDICARE