Provider Demographics
NPI:1508081456
Name:JOHNSON, KELLY LYNN (MA, LMFT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LYNN
Other - Last Name:LUNDMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4240 PARK GLEN RD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-5427
Mailing Address - Country:US
Mailing Address - Phone:612-925-6033
Mailing Address - Fax:612-925-8496
Practice Address - Street 1:4027 COUNTY ROAD 25
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-2629
Practice Address - Country:US
Practice Address - Phone:612-925-6033
Practice Address - Fax:612-925-8496
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1462106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist