Basic Information
| Provider Information | |||||||||
| NPI: | 1194107912 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | KASARDA | ||||||||
| OtherFirstName: | KELLY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 325 MDG, 340 MAGNOLIA CIRCLE | ||||||||
| Address2: | |||||||||
| City: | TYNDALL AFB | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8502837511 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 75 MDG, MENTAL HEALTH CLINIC | ||||||||
| Address2: | 7309 BALMER STREET, BLDG 545 | ||||||||
| City: | HILL AFB | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017777909 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2015 | ||||||||
| LastUpdateDate: | 01/31/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 089.0114986 | VT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.