Provider Demographics
NPI:1104300037
Name:JOHNSON, DARWIN RAND
Entity type:Individual
Prefix:
First Name:DARWIN
Middle Name:RAND
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 W SOUTHERN AVE APT 1028
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-5040
Mailing Address - Country:US
Mailing Address - Phone:928-848-2420
Mailing Address - Fax:
Practice Address - Street 1:16455 E AVENUE OF THE FOUNTAINS
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-8307
Practice Address - Country:US
Practice Address - Phone:623-404-4143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-17
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant