Provider Demographics
NPI:1568634749
Name:JOHNSON, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
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 1:6843 MAYHEW LAKE RD NE
Mailing Address - Street 2:
Mailing Address - City:SAUK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56379-9773
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6843 MAYHEW LAKE RD NE
Practice Address - Street 2:
Practice Address - City:SAUK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56379-9773
Practice Address - Country:US
Practice Address - Phone:320-492-3658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-28
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103554225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist