Provider Demographics
NPI:1043999337
Name:JOHNSON, KRISTY (LADC)
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:KRISTY
Other - Middle Name:
Other - Last Name:GELINEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2042 WOODDALE DR STE 220
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1003 CLOQUET AVE STE 117
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-1649
Practice Address - Country:US
Practice Address - Phone:218-879-5545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)