1386671782 NPI number — SUE ANN JOHNSON OTR/L

Table of content: SUE ANN JOHNSON OTR/L (NPI 1386671782)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386671782 NPI number — SUE ANN JOHNSON OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
SUE
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386671782
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
486 BYRON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRIDAY HARBOR
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98250-6967
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-378-3214
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
849 SPRING ST
Provider Second Line Business Practice Location Address:
#1
Provider Business Practice Location Address City Name:
FRIDAY HARBOR
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98250-9376
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-370-5226
Provider Business Practice Location Address Fax Number:
360-370-5559
Provider Enumeration Date:
06/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  OT00002660 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7822JO . This is a "REGENCE INDIVIDUAL RIDER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8396921 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7697576 . This is a "AETNA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0184889 . This is a "L&I INDIVIDUAL NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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