Provider Demographics
NPI:1598133779
Name:JOHNSON, KIMBERLY K (DR, LCPC, NCC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:K
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DR, LCPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1543 STONEFIELD DR
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-8906
Mailing Address - Country:US
Mailing Address - Phone:815-517-1392
Mailing Address - Fax:
Practice Address - Street 1:1543 STONEFIELD DR
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-8906
Practice Address - Country:US
Practice Address - Phone:815-517-1392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-04
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.009542101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional