Provider Demographics
NPI:1750646022
Name:JOHNSON, EBONIE (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:EBONIE
Middle Name:
Last Name:JOHNSON
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 1:7228 WALLACE RD
Mailing Address - Street 2:APT 734
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-6965
Mailing Address - Country:US
Mailing Address - Phone:347-331-6494
Mailing Address - Fax:
Practice Address - Street 1:135 E UPSAL ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119-2340
Practice Address - Country:US
Practice Address - Phone:267-335-4602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC010691225X00000X
NC9213225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist