Provider Demographics
NPI:1689705204
Name:JOHNSON, KATHLEEN H (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:H
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4711 GOLF RD SUITE 1200
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076
Mailing Address - Country:US
Mailing Address - Phone:847-677-0441
Mailing Address - Fax:847-679-8002
Practice Address - Street 1:4711 GOLF RD SUITE 1200
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076
Practice Address - Country:US
Practice Address - Phone:847-677-0441
Practice Address - Fax:847-679-8002
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-07-86892084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL947470Medicare ID - Type Unspecified
ILE54912Medicare UPIN