Provider Demographics
NPI:1386183853
Name:JOHNSON, CELESE (OTR/L)
Entity Type:Individual
Prefix:
First Name:CELESE
Middle Name:
Last Name:JOHNSON
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 1:4807 VICTORIA CHASE CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-5206
Mailing Address - Country:US
Mailing Address - Phone:732-618-3048
Mailing Address - Fax:
Practice Address - Street 1:5100 S DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4118
Practice Address - Country:US
Practice Address - Phone:773-966-5039
Practice Address - Fax:872-813-4175
Is Sole Proprietor?:No
Enumeration Date:2017-02-17
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
IL056.013821225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician