Provider Demographics
NPI:1477900553
Name:JOHNSON, KASSIDI MACEMORE (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:KASSIDI
Middle Name:MACEMORE
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 1:298 SAND PIPER LN
Mailing Address - Street 2:
Mailing Address - City:HOLDEN BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28462-1961
Mailing Address - Country:US
Mailing Address - Phone:336-918-3431
Mailing Address - Fax:
Practice Address - Street 1:237 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-4471
Practice Address - Country:US
Practice Address - Phone:336-918-3431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-19
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9249224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant