Provider Demographics
NPI:1750632089
Name:JOHNSON, KELLIE RENAE (PTA)
Entity Type:Individual
Prefix:MS
First Name:KELLIE
Middle Name:RENAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 SW 6TH AVE STE B
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66606-1582
Mailing Address - Country:US
Mailing Address - Phone:785-233-5500
Mailing Address - Fax:785-233-5512
Practice Address - Street 1:1315 SW 6TH AVE STE B
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66606-1582
Practice Address - Country:US
Practice Address - Phone:785-233-5500
Practice Address - Fax:785-233-5512
Is Sole Proprietor?:No
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1402169174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist