Provider Demographics
NPI:1639296759
Name:JOHNSON, KELLEY LYNN (LCPC-S, LCAC)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:
Credentials:LCPC-S, LCAC
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:
Other - Last Name:FERGUSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1223
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-1223
Mailing Address - Country:US
Mailing Address - Phone:620-796-2206
Mailing Address - Fax:620-796-2208
Practice Address - Street 1:809 S PATTON
Practice Address - Street 2:PO BOX 1223
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530
Practice Address - Country:US
Practice Address - Phone:620-796-2206
Practice Address - Fax:620-796-2208
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS660101YA0400X
KS2362101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100098090AMedicaid