Provider Demographics
NPI:1235974833
Name:JOHNSON, KYLEE VIOLET (MA)
Entity type:Individual
Prefix:
First Name:KYLEE
Middle Name:VIOLET
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 HUNTINGTON DR
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-4051
Mailing Address - Country:US
Mailing Address - Phone:320-282-6535
Mailing Address - Fax:
Practice Address - Street 1:1720 BASSETT DR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6569
Practice Address - Country:US
Practice Address - Phone:507-682-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician