Provider Demographics
NPI:1235741331
Name:JOHNSON, KELLIE LUCILLE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:LUCILLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 YORK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1925
Mailing Address - Country:US
Mailing Address - Phone:630-575-1980
Mailing Address - Fax:
Practice Address - Street 1:7212 W 135TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66223-1258
Practice Address - Country:US
Practice Address - Phone:913-275-5343
Practice Address - Fax:913-320-2235
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020027177225100000X
KS11-06561225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist