Provider Demographics
NPI:1801450374
Name:JOHNSON, TAYLOR ELIZABETH (OT)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:ELIZABETH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:E
Other - Last Name:PENA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:820 ELM STREET
Mailing Address - Street 2:
Mailing Address - City:ST. MARIES
Mailing Address - State:ID
Mailing Address - Zip Code:83864
Mailing Address - Country:US
Mailing Address - Phone:208-245-4576
Mailing Address - Fax:208-245-2138
Practice Address - Street 1:820 ELM STREET
Practice Address - Street 2:
Practice Address - City:ST. MARIES
Practice Address - State:ID
Practice Address - Zip Code:83864
Practice Address - Country:US
Practice Address - Phone:208-245-4576
Practice Address - Fax:208-245-2138
Is Sole Proprietor?:No
Enumeration Date:2019-04-30
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-2049225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist