Provider Demographics
NPI:1023330248
Name:JOHNSON, IMAN LEE (OTR/L)
Entity type:Individual
Prefix:
First Name:IMAN
Middle Name:LEE
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:PO BOX 27
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85211-0027
Mailing Address - Country:US
Mailing Address - Phone:480-668-1917
Mailing Address - Fax:480-668-2750
Practice Address - Street 1:1000 E MESQUITE ST
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-1814
Practice Address - Country:US
Practice Address - Phone:480-668-1917
Practice Address - Fax:480-668-2750
Is Sole Proprietor?:No
Enumeration Date:2010-02-16
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4519225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist