Provider Demographics
NPI:1548936198
Name:JOHNSON, RACHAEL
Entity type:Individual
Prefix:
First Name:RACHAEL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 WAR EAGLE BLVD
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-4235
Mailing Address - Country:US
Mailing Address - Phone:321-795-6224
Mailing Address - Fax:
Practice Address - Street 1:2040 FLORIDA A1A
Practice Address - Street 2:
Practice Address - City:INDIAN HARBOUR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937
Practice Address - Country:US
Practice Address - Phone:321-773-8989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11836224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant