Provider Demographics
NPI:1174712996
Name:JOHNSON, MARY MILLER (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:MILLER
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1784 ELKAHATCHEE RD
Mailing Address - Street 2:
Mailing Address - City:ALEX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:35010-4800
Mailing Address - Country:US
Mailing Address - Phone:256-329-0868
Mailing Address - Fax:256-329-1101
Practice Address - Street 1:1784 ELKAHATCHEE RD
Practice Address - Street 2:
Practice Address - City:ALEX CITY
Practice Address - State:AL
Practice Address - Zip Code:35010-4800
Practice Address - Country:US
Practice Address - Phone:256-329-0868
Practice Address - Fax:256-329-1101
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0299171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL0299OtherOT ALABAMA LIC.