Provider Demographics
NPI:1568537058
Name:JOHNSON, T KELLY (LAC)
Entity Type:Individual
Prefix:
First Name:T
Middle Name:KELLY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:726 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:SD
Mailing Address - Zip Code:57042-3519
Mailing Address - Country:US
Mailing Address - Phone:605-270-0347
Mailing Address - Fax:
Practice Address - Street 1:726 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:SD
Practice Address - Zip Code:57042-3519
Practice Address - Country:US
Practice Address - Phone:605-270-0347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)