Provider Demographics
NPI:1043809023
Name:KELLY, JOHNIE M JR (CACMT)
Entity Type:Individual
Prefix:MR
First Name:JOHNIE
Middle Name:M
Last Name:KELLY
Suffix:JR
Gender:M
Credentials:CACMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94043-4204
Mailing Address - Country:US
Mailing Address - Phone:650-810-6582
Mailing Address - Fax:
Practice Address - Street 1:895 SHERWOOD AVE STE 101
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94022-1344
Practice Address - Country:US
Practice Address - Phone:650-810-6582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1148225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist