Provider Demographics
NPI:1154723237
Name:JOHNSEN, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:JOHNSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 N PACIFIC COAST HWY
Mailing Address - Street 2:SUITE 200 A
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-2162
Mailing Address - Country:US
Mailing Address - Phone:310-316-1610
Mailing Address - Fax:
Practice Address - Street 1:901 N PACIFIC COAST HWY
Practice Address - Street 2:SUITE 200 A
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-2162
Practice Address - Country:US
Practice Address - Phone:310-316-1610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-21
Last Update Date:2014-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist