Provider Demographics
NPI:1164124863
Name:JOHNSON, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
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:PO BOX 1011
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:SC
Mailing Address - Zip Code:29745-1011
Mailing Address - Country:US
Mailing Address - Phone:910-988-0573
Mailing Address - Fax:
Practice Address - Street 1:1211 PLEASANT COLONY LN
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:SC
Practice Address - Zip Code:29745-7745
Practice Address - Country:US
Practice Address - Phone:910-988-0573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCBACB620951106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician