Provider Demographics
NPI:1639316433
Name:JOHNSON, SARA N (OT)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:N
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:N
Other - Last Name:BROCKMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:1410 LONG RUN RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-4334
Mailing Address - Country:US
Mailing Address - Phone:502-244-8011
Mailing Address - Fax:502-244-6631
Practice Address - Street 1:1410 LONG RUN RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40245-4334
Practice Address - Country:US
Practice Address - Phone:502-244-8011
Practice Address - Fax:502-244-6631
Is Sole Proprietor?:No
Enumeration Date:2009-01-15
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31005038A225X00000X
KYR4085225X00000X
KY132067225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50026124OtherPASSPORT
KY7100085590Medicaid
KY000000601542OtherANTHEM
KY000000601542OtherANTHEM
KY01049002Medicare PIN