Provider Demographics
NPI:1205482460
Name:KELLY C. JOHNSON LCSW, P.L.L.C.
Entity type:Organization
Organization Name:KELLY C. JOHNSON LCSW, P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:C
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:919-437-6627
Mailing Address - Street 1:2530 MERIDIAN PARKWAY
Mailing Address - Street 2:SUITE 300, PBN: 3071
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-5273
Mailing Address - Country:US
Mailing Address - Phone:919-437-6627
Mailing Address - Fax:919-258-2490
Practice Address - Street 1:2530 MERIDIAN PARKWAY
Practice Address - Street 2:SUITE 300, PBN: 3071
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-5273
Practice Address - Country:US
Practice Address - Phone:919-437-6627
Practice Address - Fax:919-258-2490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC012146OtherSTATE LICENSE
IL149019599OtherSTATE LICENSE
1427573476OtherNPI NUMBER