MEDICARE: MRS. KELLY COLLEEN JOHNSON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	149.019599	IL
2	1041C0700X	Clinical Social Worker	C012146	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C012146	OTHER	NC	STATE LICENSE
2	1427573476	OTHER		NPI TYPE I
3	149019599	OTHER	IL	STATE LICENSE

General Provider Information

NPI Number	:	1427573476
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY COLLEEN JOHNSON LCSW

Provider Business Mailing Address
First Line	:	44 RELICT DR
Second Line	:
City	:	CLAYTON
State	:	NC
Zip	:	27527-6710
Country	:	US
Telephone Number	:	815-878-8541
Fax Number	:

Provider Business Practice Location Address
First Line	:	2530 MERIDIAN PARKWAY
Second Line	:	SUITE 300, PBN: 3071
City	:	DURHAM
State	:	NC
Zip	:	27713-2771
Country	:	US
Telephone Number	:	919-437-6627
Fax Number	:	919-258-2490

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2017
Last Update Date	:	08/14/2019

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Directions to “ MRS. KELLY COLLEEN JOHNSON LCSW” Practice Location

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