Provider Demographics
NPI:1194288753
Name:JOHNSON, KELLY MILLS (PSYD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:MILLS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:J
Other - Last Name:MILLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:1423 BROADWAY STE 136
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-2054
Mailing Address - Country:US
Mailing Address - Phone:415-294-0412
Mailing Address - Fax:
Practice Address - Street 1:1423 BROADWAY STE 136
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-2054
Practice Address - Country:US
Practice Address - Phone:415-294-0412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY30455103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical