Provider Demographics
NPI:1457940769
Name:JOHNSON, MIKAILA ANN (OTR)
Entity Type:Individual
Prefix:
First Name:MIKAILA
Middle Name:ANN
Last Name:JOHNSON
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:PO BOX 81
Mailing Address - Street 2:
Mailing Address - City:HUMPTULIPS
Mailing Address - State:WA
Mailing Address - Zip Code:98552-0081
Mailing Address - Country:US
Mailing Address - Phone:360-593-2269
Mailing Address - Fax:
Practice Address - Street 1:800 N MEDCALF ST
Practice Address - Street 2:
Practice Address - City:MONTESANO
Practice Address - State:WA
Practice Address - Zip Code:98563
Practice Address - Country:US
Practice Address - Phone:360-249-2273
Practice Address - Fax:610-925-7895
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT.OT.61129636225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist