Provider Demographics
NPI:1871263889
Name:JOHNSON, MARY KATHERINE (OTR/L)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KATHERINE
Other - Last Name:CAGGIANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:61 NIMS AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-6304
Mailing Address - Country:US
Mailing Address - Phone:610-937-4528
Mailing Address - Fax:
Practice Address - Street 1:1400 OLD COUNTRY RD STE C103N
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-5156
Practice Address - Country:US
Practice Address - Phone:516-806-6969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-20
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022790-01225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist