Provider Demographics
NPI:1386250462
Name:GEBHARDT JOHNSON, KALYN M (PHD)
Entity type:Individual
Prefix:DR
First Name:KALYN
Middle Name:M
Last Name:GEBHARDT 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 1:620 W BROWN ST
Mailing Address - Street 2:
Mailing Address - City:WAUPUN
Mailing Address - State:WI
Mailing Address - Zip Code:53963-1702
Mailing Address - Country:US
Mailing Address - Phone:920-210-7256
Mailing Address - Fax:
Practice Address - Street 1:620 W BROWN ST
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-1702
Practice Address - Country:US
Practice Address - Phone:920-324-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2023-10-03
Deactivation Date:2022-10-04
Deactivation Code:
Reactivation Date:2022-10-14
Provider Licenses
StateLicense IDTaxonomies
WI5109-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist