Provider Demographics
NPI:1750692406
Name:JOHNSON, ELIZABETH (OTR-L)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OTR-L
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:CASTRALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR-L
Mailing Address - Street 1:2920 10TH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-6602
Mailing Address - Country:US
Mailing Address - Phone:812-376-9404
Mailing Address - Fax:
Practice Address - Street 1:2920 10TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-6602
Practice Address - Country:US
Practice Address - Phone:812-376-9404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31005764A225X00000X
AZ4591225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ529958Medicaid