Basic Information
| Provider Information | |||||||||
| NPI: | 1891275558 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | ALVIN | ||||||||
| MiddleName: | RAY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | OTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8038 W ELIZABETH LN | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761165130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038512285 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7804 VIRGIL ANTHONY BLVD | ||||||||
| Address2: | |||||||||
| City: | WATAUGA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761482456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174987220 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2018 | ||||||||
| LastUpdateDate: | 08/21/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 212947 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.