Provider Demographics
NPI:1497261887
Name:JOHNSON, MIKKAYLA MAE (OT)
Entity Type:Individual
Prefix:
First Name:MIKKAYLA
Middle Name:MAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15707 50TH AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-3421
Mailing Address - Country:US
Mailing Address - Phone:952-221-9990
Mailing Address - Fax:
Practice Address - Street 1:1891 STATION PKWY NW
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-3341
Practice Address - Country:US
Practice Address - Phone:763-755-4275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105555225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist