Healthcare Provider Details

I. General information

NPI: 1386412534
Provider Name (Legal Business Name): KELSEY TERESA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2023
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3755 E MAIN ST STE 190
SAINT CHARLES IL
60174-2463
US

IV. Provider business mailing address

3755 E MAIN ST STE 190
SAINT CHARLES IL
60174-2463
US

V. Phone/Fax

Practice location:
  • Phone: 630-549-6245
  • Fax: 630-701-9500
Mailing address:
  • Phone: 630-549-6245
  • Fax: 630-701-9500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150.112590
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: