Provider Demographics
NPI:1891013843
Name:JOHANSON-GRIMES, LORI ANN (OT)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:ANN
Last Name:JOHANSON-GRIMES
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:ANN
Other - Last Name:JOHANSON-GRIMES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OT
Mailing Address - Street 1:1455 46TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-4103
Mailing Address - Country:US
Mailing Address - Phone:727-526-2469
Mailing Address - Fax:
Practice Address - Street 1:1455 46TH AVE NE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33703-4103
Practice Address - Country:US
Practice Address - Phone:727-526-2469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-13
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2942225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist