Provider Demographics
NPI:1851823595
Name:JOHNERSON, KELLY (LMFTA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:JOHNERSON
Suffix:
Gender:F
Credentials:LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11002 122ND LN NE
Mailing Address - Street 2:APT K82
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98033-4690
Mailing Address - Country:US
Mailing Address - Phone:209-872-4997
Mailing Address - Fax:
Practice Address - Street 1:11002 122ND LN NE
Practice Address - Street 2:APT K82
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-4690
Practice Address - Country:US
Practice Address - Phone:209-872-4997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-31
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMG 60685775106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist