Provider Demographics
NPI:1134421373
Name:CAMPO, JOHANNA (MS, OTR/L)
Entity type:Individual
Prefix:MS
First Name:JOHANNA
Middle Name:
Last Name:CAMPO
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1523 73RD ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11228-2113
Mailing Address - Country:US
Mailing Address - Phone:631-834-9796
Mailing Address - Fax:
Practice Address - Street 1:1523 73RD ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11228-2113
Practice Address - Country:US
Practice Address - Phone:631-834-9796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-19
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016349-1225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics