Provider Demographics
NPI:1386671782
Name:JOHNSON, SUE ANN (OTR/L)
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:ANN
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 1:486 BYRON RD
Mailing Address - Street 2:
Mailing Address - City:FRIDAY HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98250-6967
Mailing Address - Country:US
Mailing Address - Phone:360-378-3214
Mailing Address - Fax:
Practice Address - Street 1:849 SPRING ST
Practice Address - Street 2:#1
Practice Address - City:FRIDAY HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98250-9376
Practice Address - Country:US
Practice Address - Phone:360-370-5226
Practice Address - Fax:360-370-5559
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00002660225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7822JOOtherREGENCE INDIVIDUAL RIDER
WA8396921Medicaid
WA7697576OtherAETNA
WA0184889OtherL&I INDIVIDUAL NUMBER
WA8803222Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NUMBE