Provider Demographics
NPI:1407975642
Name:HANSON, RANDI JOHNSON (MSRS, OTR/L)
Entity Type:Individual
Prefix:MS
First Name:RANDI
Middle Name:JOHNSON
Last Name:HANSON
Suffix:
Gender:F
Credentials:MSRS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27555 RIMROCK RD
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-4230
Mailing Address - Country:US
Mailing Address - Phone:760-252-2515
Mailing Address - Fax:
Practice Address - Street 1:27555 RIMROCK RD
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-4230
Practice Address - Country:US
Practice Address - Phone:760-252-2515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3352-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1037557OtherNBCOT NUMBER
CA14011OtherLICENSURE FOR OCCUPATIONAL THERAPIS
WI40896400Medicaid