Provider Demographics
NPI:1295033587
Name:JOHNSON, SHELLY ILENE
Entity Type:Individual
Prefix:MS
First Name:SHELLY
Middle Name:ILENE
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 1:21905 S FINLEY RD
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99337-8733
Mailing Address - Country:US
Mailing Address - Phone:509-396-9112
Mailing Address - Fax:
Practice Address - Street 1:21905 S FINLEY RD
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99337-8733
Practice Address - Country:US
Practice Address - Phone:509-396-9112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-10
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst