Provider Demographics
NPI:1699549865
Name:JOHNSON, KAYTLYN MARIE
Entity type:Individual
Prefix:
First Name:KAYTLYN
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2917 WILLIAMS DR
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-1921
Mailing Address - Country:US
Mailing Address - Phone:224-805-7004
Mailing Address - Fax:
Practice Address - Street 1:200 E 5TH AVE STE 109
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-3173
Practice Address - Country:US
Practice Address - Phone:312-646-0238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-08
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178019515101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional