Provider Demographics
NPI:1164921615
Name:JOHNSEN, KELLIE (LMFT, CST)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:JOHNSEN
Suffix:
Gender:F
Credentials:LMFT, CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51-015 LAU PL
Mailing Address - Street 2:
Mailing Address - City:KAAAWA
Mailing Address - State:HI
Mailing Address - Zip Code:96730-9817
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:970 N KALAHEO AVE STE A212
Practice Address - Street 2:
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-1857
Practice Address - Country:US
Practice Address - Phone:808-753-3329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-09
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIHI-731106H00000X
HIMFT-731106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI1164921615Medicaid