Provider Demographics
NPI:1326063033
Name:JOHNSON, RETTA PASCHAL (OTR/L, CHT)
Entity Type:Individual
Prefix:MS
First Name:RETTA
Middle Name:PASCHAL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OTR/L, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 723
Mailing Address - Street 2:
Mailing Address - City:TRUSSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35173-0723
Mailing Address - Country:US
Mailing Address - Phone:205-960-9995
Mailing Address - Fax:205-661-9841
Practice Address - Street 1:4901 DEERFOOT PKWY
Practice Address - Street 2:STE 200
Practice Address - City:TRUSSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35173-2697
Practice Address - Country:US
Practice Address - Phone:205-960-9995
Practice Address - Fax:205-661-9841
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0289225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51001814OtherBLUE CROSS BLUE SHIELD
AL51001811OtherBLUE CROSS BLUE SHEILD
AL9423173OtherPRIVATE HEALTHCARE SYSTE
AL9423173OtherPRIVATE HEALTHCARE SYSTE
AL51556733Medicare ID - Type Unspecified