Provider Demographics
NPI:1376873455
Name:JOHNSON, JOAN M (OT)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OT
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 4037
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4037
Mailing Address - Country:US
Mailing Address - Phone:503-413-4048
Mailing Address - Fax:503-413-2910
Practice Address - Street 1:19250 SW 65TH AVE
Practice Address - Street 2:MEDICAL PLAZA, SUITE 125
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7452
Practice Address - Country:US
Practice Address - Phone:503-692-1817
Practice Address - Fax:503-692-1669
Is Sole Proprietor?:No
Enumeration Date:2010-01-12
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1069889225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist