Provider Demographics
NPI:1366867806
Name:JOHNSON, KELLY (LCSW)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7324 HIGHWAY 789
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520
Mailing Address - Country:US
Mailing Address - Phone:307-349-2359
Mailing Address - Fax:307-332-9250
Practice Address - Street 1:7324 HIGHWAY 789
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520
Practice Address - Country:US
Practice Address - Phone:307-349-2359
Practice Address - Fax:307-332-9250
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-20
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW-4711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical