Healthcare Provider Details

I. General information

NPI: 1104127448
Provider Name (Legal Business Name): KELLI F JOHNSON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2010
Last Update Date: 11/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 N WABASH AVE SUITE 4003
CHICAGO IL
60611-3591
US

IV. Provider business mailing address

5312 N WINTHROP AVE 4S
CHICAGO IL
60640-2389
US

V. Phone/Fax

Practice location:
  • Phone: 850-980-2233
  • Fax:
Mailing address:
  • Phone: 850-980-2233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number071.007472
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: