Provider Demographics
NPI:1669065595
Name:JOHNSON, MACIE TAYLOR (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:MACIE
Middle Name:TAYLOR
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6015 LOMBARD RD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDER
Mailing Address - State:AR
Mailing Address - Zip Code:72002-9223
Mailing Address - Country:US
Mailing Address - Phone:501-794-7871
Mailing Address - Fax:
Practice Address - Street 1:207 PLAZA BLVD BLDG BRIDGES
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-3749
Practice Address - Country:US
Practice Address - Phone:501-794-7871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR3410225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist