Provider Demographics
NPI:1114667813
Name:JOHANNESEN, KIMBERLEE A
Entity Type:Individual
Prefix:
First Name:KIMBERLEE
Middle Name:A
Last Name:JOHANNESEN
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 1:8906 CARDWELL LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77055-4732
Mailing Address - Country:US
Mailing Address - Phone:713-416-1921
Mailing Address - Fax:
Practice Address - Street 1:20 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-4109
Practice Address - Country:US
Practice Address - Phone:312-252-7718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-30
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.001177101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional