Provider Demographics
NPI:1447015706
Name:JOHNSON, KAITLAN
Entity type:Individual
Prefix:
First Name:KAITLAN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24W500 MAPLE AVE STE 216A
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-6003
Mailing Address - Country:US
Mailing Address - Phone:090-458-2340
Mailing Address - Fax:844-270-7898
Practice Address - Street 1:24W500 MAPLE AVE STE 216A
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-6003
Practice Address - Country:US
Practice Address - Phone:630-423-6010
Practice Address - Fax:844-270-7898
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-15
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180015723101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional