Provider Demographics
NPI:1467992206
Name:HALLSTROM, JOHAN (MS OT)
Entity Type:Individual
Prefix:
First Name:JOHAN
Middle Name:
Last Name:HALLSTROM
Suffix:
Gender:M
Credentials:MS OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 CAUSEWAY DR STE B6
Mailing Address - Street 2:
Mailing Address - City:WRIGHTSVILLE BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28480-1954
Mailing Address - Country:US
Mailing Address - Phone:910-509-2810
Mailing Address - Fax:
Practice Address - Street 1:321 GENESEE ST
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-2611
Practice Address - Country:US
Practice Address - Phone:315-363-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-27
Last Update Date:2019-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0206941225X00000X
NC11061225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00354590Medicaid