Provider Demographics
NPI:1649770066
Name:JOHNSON, PATRICE DOMINQUE (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:PATRICE
Middle Name:DOMINQUE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BENCHLEY PL APT 3H
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10475-3348
Mailing Address - Country:US
Mailing Address - Phone:917-767-4407
Mailing Address - Fax:
Practice Address - Street 1:890 CAULDWELL AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-7302
Practice Address - Country:US
Practice Address - Phone:718-585-2950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-13
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022237225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist