Provider Demographics
NPI:1700826195
Name:JOHNSON, KRISTINE L (PHD)
Entity Type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:
Other - Last Name:MCIVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1105 JANA CT
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-4417
Mailing Address - Country:US
Mailing Address - Phone:785-218-4426
Mailing Address - Fax:
Practice Address - Street 1:1201 WAKARUSA DR, BLDG E
Practice Address - Street 2:SUITE E-2
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-4722
Practice Address - Country:US
Practice Address - Phone:785-434-3479
Practice Address - Fax:785-384-5618
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1118103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P72729Medicare UPIN
119669Medicare ID - Type Unspecified