Provider Demographics
NPI:1043802580
Name:JOHNSON, KIMBERLEY K
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:K
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:PO BOX 963
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32756-0963
Mailing Address - Country:US
Mailing Address - Phone:944-668-6222
Mailing Address - Fax:888-975-0599
Practice Address - Street 1:2785 S BAY ST STE A
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-6591
Practice Address - Country:US
Practice Address - Phone:844-668-6222
Practice Address - Fax:888-975-0599
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-05
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-154465106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician