Provider Demographics
NPI:1649721044
Name:JOHNSON, CHARLENE YVETTE (COTA/L)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:YVETTE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:743 HILL AVE
Mailing Address - Street 2:APT#1
Mailing Address - City:SHELBY
Mailing Address - State:MT
Mailing Address - Zip Code:59474-2717
Mailing Address - Country:US
Mailing Address - Phone:949-292-2176
Mailing Address - Fax:
Practice Address - Street 1:743 HILL AVE
Practice Address - Street 2:APT#1
Practice Address - City:SHELBY
Practice Address - State:MT
Practice Address - Zip Code:59474-2717
Practice Address - Country:US
Practice Address - Phone:949-292-2176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTA3306224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant