Provider Demographics
NPI:1376655639
Name:JOHNSON, CRYSTAL LEIGHANN (OT)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LEIGHANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 739
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:TN
Mailing Address - Zip Code:37058-0739
Mailing Address - Country:US
Mailing Address - Phone:731-641-8111
Mailing Address - Fax:731-641-8110
Practice Address - Street 1:109 COMMERCE ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TN
Practice Address - Zip Code:38242-4917
Practice Address - Country:US
Practice Address - Phone:731-641-8111
Practice Address - Fax:731-641-8110
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3643225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN33297OtherTLC
TNP00103288OtherPALMETTO GBA RR MEDICARE
12115OtherVA
TN3729568Medicaid
TN4158884OtherBLUE CROSS
TNP00103288OtherPALMETTO GBA RR MEDICARE