Provider Demographics
NPI:1962654301
Name:JOHNSON, KEVIN RICHARD (COTA)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:RICHARD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 E ALFRED ST
Mailing Address - Street 2:
Mailing Address - City:WEYAUWEGA
Mailing Address - State:WI
Mailing Address - Zip Code:54983-9024
Mailing Address - Country:US
Mailing Address - Phone:920-867-3121
Mailing Address - Fax:920-867-3997
Practice Address - Street 1:717 E ALFRED ST
Practice Address - Street 2:
Practice Address - City:WEYAUWEGA
Practice Address - State:WI
Practice Address - Zip Code:54983-9024
Practice Address - Country:US
Practice Address - Phone:920-867-3121
Practice Address - Fax:920-867-3997
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-16
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1141-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1141-027OtherNPI