Provider Demographics
NPI:1134392657
Name:JOHNSON, CANDACE D (OTR/L)
Entity type:Individual
Prefix:MS
First Name:CANDACE
Middle Name:D
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 1:7737 S KINGSTON AVE
Mailing Address - Street 2:UNIT #1N
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-4713
Mailing Address - Country:US
Mailing Address - Phone:773-540-1434
Mailing Address - Fax:
Practice Address - Street 1:7737 S KINGSTON AVE
Practice Address - Street 2:UNIT #1N
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-4713
Practice Address - Country:US
Practice Address - Phone:773-540-1434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-04
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist