Provider Demographics
NPI:1821289067
Name:JOHNSON, KASSY AMBER (PHD)
Entity Type:Individual
Prefix:
First Name:KASSY
Middle Name:AMBER
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2365 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:KS
Mailing Address - Zip Code:67042-3208
Mailing Address - Country:US
Mailing Address - Phone:316-321-6036
Mailing Address - Fax:
Practice Address - Street 1:2365 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:KS
Practice Address - Zip Code:67042-3208
Practice Address - Country:US
Practice Address - Phone:316-321-6036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1697103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical