Provider Demographics
NPI:1447744347
Name:JOHNSON, KELLY THERESA
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:THERESA
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 1:3409 WISCONSIN AVE NW APT 2
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20016-3008
Mailing Address - Country:US
Mailing Address - Phone:203-233-1678
Mailing Address - Fax:
Practice Address - Street 1:5272 RIVER RD STE 100
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20816-1454
Practice Address - Country:US
Practice Address - Phone:703-429-1853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2204000112235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist