Provider Demographics
NPI:1134411648
Name:JOHNSON, KRYSTLE (ITFS)
Entity type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ITFS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6732 BILTMORE GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89149-0226
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4085 N RANCHO DR
Practice Address - Street 2:SUITE 120
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3466
Practice Address - Country:US
Practice Address - Phone:702-349-8258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-03
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC174400000X, 222Q00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No174400000XOther Service ProvidersSpecialist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor