Provider Demographics
NPI:1851413223
Name:JOHNSON, SHANNON L (OT)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:MISS
Other - First Name:SHANNON
Other - Middle Name:L
Other - Last Name:STORIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:1177 ROSE LN
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-6443
Mailing Address - Country:US
Mailing Address - Phone:206-579-6263
Mailing Address - Fax:
Practice Address - Street 1:3915 GOLDEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4249
Practice Address - Country:US
Practice Address - Phone:763-520-0715
Practice Address - Fax:763-520-0355
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2009-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00004279225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist