Provider Demographics
NPI:1417428764
Name:JOHNSON, KELSEY S R (LPC)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:S R
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 RENSVOLD BLVD
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-3242
Mailing Address - Country:US
Mailing Address - Phone:952-221-6397
Mailing Address - Fax:
Practice Address - Street 1:2010 EASTWOOD DR STE 202
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-5387
Practice Address - Country:US
Practice Address - Phone:608-255-9119
Practice Address - Fax:608-255-9219
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2023-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7155-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional