Provider Demographics
NPI:1669571261
Name:JOHNSTON, STACY LEA (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:LEA
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:LEA
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:4415 36 1/2 STREET WEST
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416
Mailing Address - Country:US
Mailing Address - Phone:952-927-9717
Mailing Address - Fax:952-927-7687
Practice Address - Street 1:4415 36 1/2 STREET WEST
Practice Address - Street 2:
Practice Address - City:ST. LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416
Practice Address - Country:US
Practice Address - Phone:952-927-9717
Practice Address - Fax:952-927-7687
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN100740225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist