MEDICARE: DR. KELLY CONNORS JOHNSON PH.D., L.P.

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	103T00000X	Psychologist	6301013076	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0H27229	OTHER	MI	BLUE CROSS BLUE SHIELD OF MICHIGAN

General Provider Information

NPI Number	:	1972754307
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY CONNORS JOHNSON PH.D., L.P.

Provider Business Mailing Address
First Line	:	PO BOX 1492
Second Line	:
City	:	BELLEVILLE
State	:	MI
Zip	:	48112-1492
Country	:	US
Telephone Number	:	734-799-6047
Fax Number	:

Provider Business Practice Location Address
First Line	:	159 MAIN ST
Second Line	:
City	:	BELLEVILLE
State	:	MI
Zip	:	48111-2737
Country	:	US
Telephone Number	:	734-799-6047
Fax Number	:

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

Provider Enumeration Date	:	10/03/2008
Last Update Date	:	04/16/2013

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