Provider Demographics
NPI:1932250016
Name:JOHANNES, KELLEY N (PT)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:N
Last Name:JOHANNES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 DEWFIELD LN
Mailing Address - Street 2:
Mailing Address - City:BOILING SPRINGS
Mailing Address - State:SC
Mailing Address - Zip Code:29316-6167
Mailing Address - Country:US
Mailing Address - Phone:704-785-5152
Mailing Address - Fax:
Practice Address - Street 1:2400 WINCHESTER PL STE 102B
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-1518
Practice Address - Country:US
Practice Address - Phone:864-574-7282
Practice Address - Fax:864-574-7664
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC107922251P0200X
2251P0200X
SC68182251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics