Healthcare Provider Details

I. General information

NPI: 1669031852
Provider Name (Legal Business Name): KELLEY JOHNSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 07/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4455 S PECOS RD STE C
LAS VEGAS NV
89121-5029
US

IV. Provider business mailing address

3928 BAGUA CT
LAS VEGAS NV
89129-7087
US

V. Phone/Fax

Practice location:
  • Phone: 702-350-1430
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KELLEY JOHNSON
Title or Position: OWNER
Credential:
Phone: 702-810-8268