Provider Demographics
NPI:1558418640
Name:JOHNSON, KENNETH D (MA, LPC)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 DALLAS HWY SW
Mailing Address - Street 2:SUITE 230
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-2597
Mailing Address - Country:US
Mailing Address - Phone:770-419-5657
Mailing Address - Fax:770-419-5658
Practice Address - Street 1:2655 DALLAS HWY SW
Practice Address - Street 2:SUITE 230
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-2597
Practice Address - Country:US
Practice Address - Phone:770-419-5657
Practice Address - Fax:770-419-5658
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC002304101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health