Provider Demographics
NPI:1619618881
Name:JOHNSON, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
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 1:730 MAIN ST # 230
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-3030
Mailing Address - Country:US
Mailing Address - Phone:813-763-5469
Mailing Address - Fax:
Practice Address - Street 1:604 HEATHROW DRIVE
Practice Address - Street 2:UNIT 1095
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579
Practice Address - Country:US
Practice Address - Phone:740-645-7688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-04
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician