Provider Demographics
NPI:1245600964
Name:JOHNSON, LEAH DANIELLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:DANIELLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:DANIELLE
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:714 JACKSON ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-2308
Mailing Address - Country:US
Mailing Address - Phone:952-393-2831
Mailing Address - Fax:
Practice Address - Street 1:825 1ST AVE NW
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-6846
Practice Address - Country:US
Practice Address - Phone:651-633-7875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105001225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist