Provider Demographics
NPI:1871952945
Name:JOHNSON, JUSTIN D (OT)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 E HUEBBE PKWY
Mailing Address - Street 2:BELOIT HEALTH SYSTEM INC
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1842
Mailing Address - Country:US
Mailing Address - Phone:608-364-2230
Mailing Address - Fax:608-363-7395
Practice Address - Street 1:1650 LEE LN
Practice Address - Street 2:OCCUPATIONAL HEALTH AND SPORTS & FAMILY MEDICINE CENTER
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-3935
Practice Address - Country:US
Practice Address - Phone:608-362-0211
Practice Address - Fax:608-364-4670
Is Sole Proprietor?:No
Enumeration Date:2016-02-18
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5666-26225X00000X
IL056-008589225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist