Provider Demographics
NPI:1144332263
Name:ABADIAS GONZALEZ, JOHANNA (OTRL)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:ABADIAS GONZALEZ
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043-2113
Mailing Address - Country:US
Mailing Address - Phone:904-837-8056
Mailing Address - Fax:
Practice Address - Street 1:6817 SOUTHPOINT PKWY STE 1602
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6298
Practice Address - Country:US
Practice Address - Phone:904-945-7556
Practice Address - Fax:904-379-0113
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2022-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3264225X00000X
FLOT13260225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0032022269AMedicaid