Provider Demographics
NPI:1366000853
Name:JOHNSON, SHELBY A
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:A
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 1:15009 GRAND SUMMIT BLVD APT 206
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:MO
Mailing Address - Zip Code:64030-2784
Mailing Address - Country:US
Mailing Address - Phone:816-382-7587
Mailing Address - Fax:
Practice Address - Street 1:1936 SUMMIT ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-2110
Practice Address - Country:US
Practice Address - Phone:816-866-5662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician