Provider Demographics
NPI:1578086575
Name:JOHNSON, BRANDON ROSS (MOT, OTR, LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:ROSS
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MOT, OTR, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47501-1705
Mailing Address - Country:US
Mailing Address - Phone:812-887-7621
Mailing Address - Fax:
Practice Address - Street 1:1 LOOGOOTEE PLZ
Practice Address - Street 2:
Practice Address - City:LOOGOOTEE
Practice Address - State:IN
Practice Address - Zip Code:47553-5757
Practice Address - Country:US
Practice Address - Phone:812-709-3286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-21
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31005247A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist