Provider Demographics
NPI:1780728485
Name:JOHNSON, CHASSIDY (COTA)
Entity type:Individual
Prefix:
First Name:CHASSIDY
Middle Name:
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 1:8805 W 350 S
Mailing Address - Street 2:
Mailing Address - City:KIMMELL
Mailing Address - State:IN
Mailing Address - Zip Code:46760-9749
Mailing Address - Country:US
Mailing Address - Phone:260-799-4332
Mailing Address - Fax:
Practice Address - Street 1:3320 N CLINTON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1918
Practice Address - Country:US
Practice Address - Phone:260-483-2100
Practice Address - Fax:260-484-5059
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32000934A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant