Provider Demographics
NPI:1568009686
Name:JOHNSON, ISABELLA KATHRYN
Entity Type:Individual
Prefix:
First Name:ISABELLA
Middle Name:KATHRYN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3046 REGAL PARK CT
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-3899
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22 BUFORD VILLAGE WAY
Practice Address - Street 2:SUITE 229
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518
Practice Address - Country:US
Practice Address - Phone:678-482-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
GAOT008208225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician