Provider Demographics
NPI:1497150833
Name:JOHNSON, KELLI (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 FLYNN AVE
Mailing Address - Street 2:#16
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94043-3912
Mailing Address - Country:US
Mailing Address - Phone:408-406-5736
Mailing Address - Fax:
Practice Address - Street 1:272 REDWOOD SHORES PKWY
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94065-1173
Practice Address - Country:US
Practice Address - Phone:650-595-5893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-28
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34218174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist