Provider Demographics
NPI:1114588738
Name:JOHNSON, KALEB
Entity Type:Individual
Prefix:
First Name:KALEB
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2635
Mailing Address - Street 2:
Mailing Address - City:SEWARD
Mailing Address - State:AK
Mailing Address - Zip Code:99664-2635
Mailing Address - Country:US
Mailing Address - Phone:316-832-8433
Mailing Address - Fax:
Practice Address - Street 1:302 RAILWAY AVE.
Practice Address - Street 2:
Practice Address - City:SEWARD
Practice Address - State:AK
Practice Address - Zip Code:99664
Practice Address - Country:US
Practice Address - Phone:907-224-5257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician