Provider Demographics
NPI:1972754307
Name:JOHNSON, KELLY CONNORS (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:CONNORS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:MRS
Other - First Name:KELLY
Other - Middle Name:CONNORS
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD, LP
Mailing Address - Street 1:PO BOX 1492
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48112-1492
Mailing Address - Country:US
Mailing Address - Phone:734-799-6047
Mailing Address - Fax:
Practice Address - Street 1:159 MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48111-2737
Practice Address - Country:US
Practice Address - Phone:734-799-6047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-03
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013076103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H27229OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MIMI4892Medicare PIN