Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XG0600X | Occupational Therapist - Gerontology |
NPI | 1114499613 |
---|---|
Provider Name | Tyler Johnson |
First Address | Shelby Township, MI 48317-3864 |
Second Address | Rochester Hills, MI 48309-3819 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/12/2018 |
Last Update Date | 20/12/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
13225 | OCCUPATIONAL THERAPIST LICENSE (01) | CA |
5201009026 | OCCUPATIONAL THERAPIST LICENSE (01) | MI |