Healthcare Provider Details

I. General information

NPI: 1467043513
Provider Name (Legal Business Name): KYLE RAYMOND JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2021
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2210 N ELDORADO AVE
KLAMATH FALLS OR
97601-6418
US

IV. Provider business mailing address

2210 N ELDORADO AVE
KLAMATH FALLS OR
97601-6418
US

V. Phone/Fax

Practice location:
  • Phone: 541-883-1030
  • Fax:
Mailing address:
  • Phone: 541-883-1030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL16621
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number23-11-10964
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: