Provider Demographics
NPI:1639296759
Name:JOHNSON, KELLEY LYNN (LPC)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5634 EISENHOWER AVE
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-6324
Mailing Address - Country:US
Mailing Address - Phone:620-786-0311
Mailing Address - Fax:303-750-2678
Practice Address - Street 1:155 SE 1 AVE
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-9696
Practice Address - Country:US
Practice Address - Phone:620-786-0311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS753101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100098090AMedicaid