Provider Demographics
NPI:1417692401
Name:JOHNSON, LISA ANN (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38098 N HOLDRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:BEACH PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60087-5416
Mailing Address - Country:US
Mailing Address - Phone:630-890-6025
Mailing Address - Fax:
Practice Address - Street 1:1615 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60087-3810
Practice Address - Country:US
Practice Address - Phone:847-244-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty