Provider Demographics
NPI:1689790545
Name:JOHNSON, TAMARA IRENE (COTAL)
Entity Type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:IRENE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 2 BOX 246 H
Mailing Address - Street 2:TREADWAY RD.
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840
Mailing Address - Country:US
Mailing Address - Phone:304-465-1903
Mailing Address - Fax:
Practice Address - Street 1:422 23RD ST
Practice Address - Street 2:
Practice Address - City:OAK HILL
Practice Address - State:WV
Practice Address - Zip Code:25901-2830
Practice Address - Country:US
Practice Address - Phone:304-465-1903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVC1486224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant