Provider Demographics
NPI:1619863297
Name:JOHNSON, KELLE D (MT)
Entity type:Individual
Prefix:MR
First Name:KELLE
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9306 WOLCOTT PARK LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77075-3826
Mailing Address - Country:US
Mailing Address - Phone:281-986-0551
Mailing Address - Fax:
Practice Address - Street 1:9306 WOLCOTT PARK LN
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77075-3826
Practice Address - Country:US
Practice Address - Phone:281-986-0551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-18
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT108696225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist