Provider Demographics
NPI:1548769581
Name:JOHNSON, MARY ANN (OTA)
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 WEATHERSTONE CIR SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-2015
Mailing Address - Country:US
Mailing Address - Phone:770-686-6822
Mailing Address - Fax:
Practice Address - Street 1:1277 PARKER RD SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-5957
Practice Address - Country:US
Practice Address - Phone:678-615-3056
Practice Address - Fax:678-623-0136
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000082224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant