Provider Demographics
NPI:1346307527
Name:JOHNSON, KIMBERLY SUZANNE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:SUZANNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9437 W AVENIDA DEL SOL
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-1135
Mailing Address - Country:US
Mailing Address - Phone:623-215-8444
Mailing Address - Fax:480-483-1026
Practice Address - Street 1:5040 E SHEA BLVD
Practice Address - Street 2:SUITE 168
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-4600
Practice Address - Country:US
Practice Address - Phone:480-483-1025
Practice Address - Fax:480-483-1026
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2534225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ503129Medicaid