Provider Demographics
NPI:1336443753
Name:JOHNSON, ANDREA LEE (OT)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:LEE
Other - Last Name:KNESEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:2924 BROOK RD
Mailing Address - Street 2:CHILDREN'S HOSPITAL CREDENTIALING DEPT
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-1215
Mailing Address - Country:US
Mailing Address - Phone:804-321-7474
Mailing Address - Fax:804-228-5210
Practice Address - Street 1:2924 BROOK RD
Practice Address - Street 2:CHILDREN'S HOSPITAL
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220-1215
Practice Address - Country:US
Practice Address - Phone:804-321-7474
Practice Address - Fax:804-228-5210
Is Sole Proprietor?:No
Enumeration Date:2010-12-28
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119001111225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004909976Medicaid