Provider Demographics
NPI:1013429307
Name:JOHNSON, KELLI (MOTR/L)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 SNOWBIRD CT
Mailing Address - Street 2:
Mailing Address - City:NORTH MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56003-1637
Mailing Address - Country:US
Mailing Address - Phone:507-317-1814
Mailing Address - Fax:
Practice Address - Street 1:1575 HOOVER DR
Practice Address - Street 2:
Practice Address - City:NORTH MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56003-2667
Practice Address - Country:US
Practice Address - Phone:507-387-2037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-26
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105404225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist