Provider Demographics
NPI:1871241745
Name:JOHNSON, MCKENNA ANNE (OTR/L)
Entity Type:Individual
Prefix:
First Name:MCKENNA
Middle Name:ANNE
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 1:25402 139TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98042-6608
Mailing Address - Country:US
Mailing Address - Phone:253-632-6440
Mailing Address - Fax:
Practice Address - Street 1:17615 85TH AVENUE CT E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98375-1902
Practice Address - Country:US
Practice Address - Phone:253-216-2589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT61264446225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist