Provider Demographics
NPI:1760501993
Name:JOHNSON, KELLY RENEE (MAOTRL)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:RENEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MAOTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2422 PARTRIDGE LOOP
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-4944
Mailing Address - Country:US
Mailing Address - Phone:208-819-9363
Mailing Address - Fax:
Practice Address - Street 1:2422 PARTRIDGE LOOP
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-4944
Practice Address - Country:US
Practice Address - Phone:208-819-9363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD553225X00000X
IDOT-840225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5834280Medicaid