Provider Demographics
NPI:1750581757
Name:JOHNSON, BONNIE LOU (COTA)
Entity type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:LOU
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 NE 113TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-2211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11325 NE WEIDLER
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-2211
Practice Address - Country:US
Practice Address - Phone:503-251-3776
Practice Address - Fax:503-253-1871
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1020842224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant