Provider Demographics
NPI:1104127448
Name:JOHNSON, KELLI F (PHD)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:F
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5312 N WINTHROP AVE
Mailing Address - Street 2:4S
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2389
Mailing Address - Country:US
Mailing Address - Phone:850-980-2233
Mailing Address - Fax:
Practice Address - Street 1:405 N WABASH AVE
Practice Address - Street 2:SUITE 4003
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3591
Practice Address - Country:US
Practice Address - Phone:850-980-2233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.007472103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling