Provider Demographics
NPI:1649443045
Name:JOHNSON, BRENDA J (OT)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 965
Mailing Address - Street 2:
Mailing Address - City:MULDROW
Mailing Address - State:OK
Mailing Address - Zip Code:74948-0965
Mailing Address - Country:US
Mailing Address - Phone:918-427-5416
Mailing Address - Fax:
Practice Address - Street 1:2221 E POINTER TRL
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-2336
Practice Address - Country:US
Practice Address - Phone:479-651-4098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR390174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist