Provider Demographics
NPI:1558422865
Name:JOHNSON, CARRIE LYNN (COTA)
Entity Type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MS
Other - First Name:CARRIE
Other - Middle Name:LYNN
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:1208 3RD ST E
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:WI
Mailing Address - Zip Code:54720-2026
Mailing Address - Country:US
Mailing Address - Phone:715-271-1882
Mailing Address - Fax:
Practice Address - Street 1:1405 TRUAX BLVD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703-1474
Practice Address - Country:US
Practice Address - Phone:715-552-1030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2010-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1074-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40876500Medicaid