Provider Demographics
NPI:1982376489
Name:JOHNSON, MEKELL ALEXZANDRA (MOT)
Entity Type:Individual
Prefix:
First Name:MEKELL
Middle Name:ALEXZANDRA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7935 S WHIPPLE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60652-1628
Mailing Address - Country:US
Mailing Address - Phone:773-915-3259
Mailing Address - Fax:
Practice Address - Street 1:1400 BROOKDALE RD
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-2126
Practice Address - Country:US
Practice Address - Phone:630-416-6565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-02
Last Update Date:2021-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056014493225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist