Basic Information
| Provider Information | |||||||||
| NPI: | 1740650589 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | JOHNSON | ||||||||
| FirstName: | SHIRHONDA | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11901 TOEPPERWEIN RD | ||||||||
| Address2: | STE.1106 | ||||||||
| City: | LIVE OAK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782333161 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11901 TOEPPERWEIN RD | ||||||||
| Address2: | STE.1106 | ||||||||
| City: | LIVE OAK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782333161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106511900 | ||||||||
| FaxNumber: | 2106511962 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2015 | ||||||||
| LastUpdateDate: | 10/06/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 116332 | TX | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225XP0200X | 116332 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics |
No ID Information.