Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | ||
N | 225XP0019X | Occupational Therapist - Physical Rehabilitation |
NPI | 1396247920 |
---|---|
Provider Name | Talia Shakira Johnson |
First Address | Ellicott City, MD 21043-7178 |
Second Address | Windsor Mill, MD 21244-2552 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/02/2018 |
Last Update Date | 28/02/2018 |