Provider Demographics
NPI:1679762843
Name:JOHANNESEN, MICHELLE SIERRA (OTR/L)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:SIERRA
Last Name:JOHANNESEN
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 1:2810 W 35TH ST
Mailing Address - Street 2:STE 2
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-2909
Mailing Address - Country:US
Mailing Address - Phone:308-237-7388
Mailing Address - Fax:308-237-7394
Practice Address - Street 1:1301 E H ST
Practice Address - Street 2:
Practice Address - City:MC COOK
Practice Address - State:NE
Practice Address - Zip Code:69001-3482
Practice Address - Country:US
Practice Address - Phone:308-344-8383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-23
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1278225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist