Healthcare Provider Details

I. General information

NPI: 1710253869
Provider Name (Legal Business Name): KEVIN JOHNSON CLINICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2012
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 N MALL DR STE E102
ST GEORGE UT
84790-7305
US

IV. Provider business mailing address

1202 SAINT JAMES LN
ST GEORGE UT
84790-6743
US

V. Phone/Fax

Practice location:
  • Phone: 435-225-4357
  • Fax:
Mailing address:
  • Phone: 435-225-4357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5962642-3501
License Number StateUT

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MR. KEVIN R. JOHNSON
Title or Position: OWNER
Credential: LCSW
Phone: 435-225-4357