Provider Demographics
NPI:1669143152
Name:JOHNSON, KELLY KATHRYN (LCSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:KATHRYN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 66TH ST STE E
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79414-4875
Mailing Address - Country:US
Mailing Address - Phone:805-712-5225
Mailing Address - Fax:
Practice Address - Street 1:4601 66TH ST STE E
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79414-4875
Practice Address - Country:US
Practice Address - Phone:806-712-5225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX684261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical