Provider Demographics
NPI:1336773035
Name:JOHANSSON, KRISTINA ELIZABETH (OTR)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:ELIZABETH
Last Name:JOHANSSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18777 MIDWAY RD # B1003
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-2787
Mailing Address - Country:US
Mailing Address - Phone:469-394-5207
Mailing Address - Fax:
Practice Address - Street 1:1101 CENTRAL EXPY S STE 185
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-8202
Practice Address - Country:US
Practice Address - Phone:214-509-6961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120703225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120703OtherSTATE LISCENSE