Provider Demographics
NPI:1790540813
Name:JOHNSON, KAYLEE
Entity Type:Individual
Prefix:
First Name:KAYLEE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2511 PAUPAUWELA ST
Mailing Address - Street 2:
Mailing Address - City:WAHIAWA
Mailing Address - State:HI
Mailing Address - Zip Code:96786-7017
Mailing Address - Country:US
Mailing Address - Phone:419-605-6169
Mailing Address - Fax:
Practice Address - Street 1:2511 PAUPAUWELA ST
Practice Address - Street 2:
Practice Address - City:WAHIAWA
Practice Address - State:HI
Practice Address - Zip Code:96786-7017
Practice Address - Country:US
Practice Address - Phone:419-605-6169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-19
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician