Basic Information
| Provider Information | |||||||||
| NPI: | 1710209911 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | SHAUNNA | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BERG | ||||||||
| OtherFirstName: | SHAUNNA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | OT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 820 ROY ST | ||||||||
| Address2: | |||||||||
| City: | ORTONVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562781138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3208394271 | ||||||||
| FaxNumber: | 3208394196 | ||||||||
| Practice Location | |||||||||
| Address1: | 32021 COUNTY 24 BLVD | ||||||||
| Address2: | |||||||||
| City: | CANNON FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550095003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073776285 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2010 | ||||||||
| LastUpdateDate: | 02/16/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 103850 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.