Provider Demographics
NPI:1871254706
Name:JOHNSON, CHRISTAL DAWN (OTR)
Entity type:Individual
Prefix:
First Name:CHRISTAL
Middle Name:DAWN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 BYBEE LOOP
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:KY
Mailing Address - Zip Code:40385-8018
Mailing Address - Country:US
Mailing Address - Phone:859-661-9957
Mailing Address - Fax:
Practice Address - Street 1:60 MERCY CT
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:KY
Practice Address - Zip Code:40336-1331
Practice Address - Country:US
Practice Address - Phone:606-723-2115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-03
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist