Provider Demographics
NPI:1225232010
Name:JOHNSON, KIMBERLY JANELL
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:JANELL
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 1:193 MARTIN WAY
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-8619
Mailing Address - Country:US
Mailing Address - Phone:270-314-5353
Mailing Address - Fax:
Practice Address - Street 1:193 MARTIN WAY
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-8619
Practice Address - Country:US
Practice Address - Phone:270-683-3381
Practice Address - Fax:270-683-3381
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY106S00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty