Basic Information
| Provider Information | |||||||||
| NPI: | 1588868210 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | SARA | ||||||||
| MiddleName: | REBECCA | ||||||||
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| Credential: | COTA-L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4690 TRAILS END | ||||||||
| Address2: | |||||||||
| City: | BAR NUNN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826019424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072514073 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2521 E 15TH ST | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826094126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072377444 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 653 | WY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.