Provider Demographics
NPI:1568569531
Name:JOHNSON, TERRY DAVID (OTR/L,CHT)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:DAVID
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OTR/L,CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1341 MEDICAL PARK DRIVE, SUITE 202
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-1225
Mailing Address - Country:US
Mailing Address - Phone:321-953-1212
Mailing Address - Fax:321-768-7829
Practice Address - Street 1:1341 MEDICAL PARK DRIVE, SUITE 202
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1225
Practice Address - Country:US
Practice Address - Phone:321-953-1212
Practice Address - Fax:321-768-7829
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT3485225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ05632Medicare ID - Type UnspecifiedMEDICARE NUMBER