Provider Demographics
NPI:1831339589
Name:JOHNSON, LYLE FOSTER (OTAL)
Entity type:Individual
Prefix:MR
First Name:LYLE
Middle Name:FOSTER
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2657 APD 40
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37323-0696
Mailing Address - Country:US
Mailing Address - Phone:423-339-1492
Mailing Address - Fax:423-339-1496
Practice Address - Street 1:2657 APD 40
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37323-0696
Practice Address - Country:US
Practice Address - Phone:423-339-1492
Practice Address - Fax:423-339-1496
Is Sole Proprietor?:No
Enumeration Date:2009-02-20
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000001096224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant