MEDICARE: KELLIE JOHANSEN LCMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor
2	101YM0800X	Mental Health Counselor	4916	NH

General Provider Information

NPI Number	:	1427694934
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLIE JOHANSEN LCMHC

Provider Business Mailing Address
First Line	:	PO BOX 292
Second Line	:
City	:	EXETER
State	:	NH
Zip	:	03833-0292
Country	:	US
Telephone Number	:	603-770-6783
Fax Number	:

Provider Business Practice Location Address
First Line	:	835 HANOVER ST STE 305
Second Line	:
City	:	MANCHESTER
State	:	NH
Zip	:	03104-5401
Country	:	US
Telephone Number	:	603-770-6783
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/19/2019
Last Update Date	:	03/04/2025

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Directions to “ KELLIE JOHANSEN LCMHC” Practice Location

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