Provider Demographics
NPI:1316217516
Name:JOHNSON III, WALLACE DANNY (MS OTR/L)
Entity Type:Individual
Prefix:MR
First Name:WALLACE
Middle Name:DANNY
Last Name:JOHNSON III
Suffix:
Gender:M
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 EMANCIPATION DRIVE
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23667
Mailing Address - Country:US
Mailing Address - Phone:757-722-9961
Mailing Address - Fax:
Practice Address - Street 1:100 EMANCIPATION DRIVE
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23667
Practice Address - Country:US
Practice Address - Phone:757-722-9961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-04
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119003661225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist