Provider Demographics
NPI:1639360514
Name:JOHNSON, RICIA RAE (OTA/L)
Entity Type:Individual
Prefix:MS
First Name:RICIA
Middle Name:RAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OTA/L
Other - Prefix:MRS
Other - First Name:RICIA
Other - Middle Name:RAE
Other - Last Name:GLOCKZIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTA
Mailing Address - Street 1:4415 WEST 36 1/2 STREET
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416
Mailing Address - Country:US
Mailing Address - Phone:952-927-9717
Mailing Address - Fax:952-927-7687
Practice Address - Street 1:4415 WEST 36 1/2 STREET
Practice Address - Street 2:
Practice Address - City:ST. LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416
Practice Address - Country:US
Practice Address - Phone:952-927-9717
Practice Address - Fax:952-927-7687
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS201244224Z00000X
MN201244224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant