Provider Demographics
NPI:1578614780
Name:JOHNSON, LAURIE JEAN (OTR)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:JEAN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:JEAN
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:17016 77TH AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-3743
Mailing Address - Country:US
Mailing Address - Phone:763-416-2788
Mailing Address - Fax:
Practice Address - Street 1:3915 GOLDEN VALLEY RD
Practice Address - Street 2:COURAGE CENTER
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4249
Practice Address - Country:US
Practice Address - Phone:763-588-0811
Practice Address - Fax:763-520-0355
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN100897225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist