Basic Information
| Provider Information | |||||||||
| NPI: | 1851923445 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHANNESSEN | ||||||||
| FirstName: | KYLE | ||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4321 ALLENDALE AVE | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558031562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187287500 | ||||||||
| FaxNumber: | 2187287501 | ||||||||
| Practice Location | |||||||||
| Address1: | 4849 IVANHOE ST | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558041131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187287418 | ||||||||
| FaxNumber: | 2187287467 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2020 | ||||||||
| LastUpdateDate: | 02/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | CC02342 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.