Provider Demographics
NPI:1427573476
Name:JOHNSON, KELLY COLLEEN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:COLLEEN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 RELICT DR
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27527-6710
Mailing Address - Country:US
Mailing Address - Phone:815-878-8541
Mailing Address - Fax:
Practice Address - Street 1:2530 MERIDIAN PARKWAY
Practice Address - Street 2:SUITE 300, PBN: 3071
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-2771
Practice Address - Country:US
Practice Address - Phone:919-437-6627
Practice Address - Fax:919-258-2490
Is Sole Proprietor?:No
Enumeration Date:2017-08-11
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0195991041C0700X
NCC0121461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC012146OtherSTATE LICENSE
1427573476OtherNPI TYPE I
IL149019599OtherSTATE LICENSE