Provider Demographics
NPI:1780252957
Name:JOHNSON, SAMANTHA LYNN (OTD)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2593 US HIGHWAY 2 E STE 1
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-9507
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2593 US HIGHWAY 2 E STE 1
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-9507
Practice Address - Country:US
Practice Address - Phone:406-890-2212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT8450225XP0200X
MTOTP-OT-PRV-8112225XP0200X
OTP-OT-LIC-8450225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty