Provider Demographics
NPI:1629366778
Name:JOHNSON, SUSAN RENE (OTR/L)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:RENE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:1210 GEMINI PL
Practice Address - Street 2:SUITE 200
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43240-6109
Practice Address - Country:US
Practice Address - Phone:614-262-0907
Practice Address - Fax:614-262-0822
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT005403225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH008870Medicare PIN