Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | OT0000000774 | TN |
NPI | 1003262494 |
---|---|
Provider Name | Mrs. Dora Johnson |
First Address | Lenoir City, TN 37772-5914 |
Second Address | Lenoir City, TN 37772-5914 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/05/2016 |
Last Update Date | 04/05/2016 |