Provider Demographics
NPI:1558095505
Name:JOHNSON, STEPHANIE (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 HOOSICK STREET
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180
Mailing Address - Country:US
Mailing Address - Phone:518-888-0034
Mailing Address - Fax:
Practice Address - Street 1:311 BOULEVARD OF AMERICAS STE 204
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-4788
Practice Address - Country:US
Practice Address - Phone:718-650-6230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021392225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist