Provider Demographics
NPI:1942573621
Name:JOHNSON, KELLY (LCSW)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
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 1:2527 W KIT CARSON TRL
Mailing Address - Street 2:
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-1877
Mailing Address - Country:US
Mailing Address - Phone:623-396-6216
Mailing Address - Fax:
Practice Address - Street 1:18205 N 51ST AVE STE 109
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-1491
Practice Address - Country:US
Practice Address - Phone:623-396-6216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-11
Last Update Date:2022-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ194231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical