Provider Demographics
NPI:1508874637
Name:JOHNSON, BRENNA STANLEY (OTR)
Entity Type:Individual
Prefix:MRS
First Name:BRENNA
Middle Name:STANLEY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 N MOUND ST
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-4427
Mailing Address - Country:US
Mailing Address - Phone:936-564-6907
Mailing Address - Fax:936-564-0509
Practice Address - Street 1:817 N MOUND ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961
Practice Address - Country:US
Practice Address - Phone:936-564-6907
Practice Address - Fax:936-564-0509
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107063174400000X, 225XP0200X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No174400000XOther Service ProvidersSpecialist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX659657OtherBCBS #
TX1637803-02Medicaid
TX1637803-01Medicaid
TX1637803-01Medicaid