Basic Information
| Provider Information | |||||||||
| NPI: | 1700062445 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | JOHNSTON | ||||||||
| NamePrefix: | |||||||||
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| Credential: | OTR/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSTON | ||||||||
| OtherFirstName: | COURTNEY | ||||||||
| OtherMiddleName: | REBAKAH | ||||||||
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| OtherCredential: | OTR/L | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3077 TESSMER RD | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481039646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065139078 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5840 INTERFACE DR | ||||||||
| Address2: | STE 400 | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481039176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346278001 | ||||||||
| FaxNumber: | 7344331989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2008 | ||||||||
| LastUpdateDate: | 01/24/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 3354 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.