Provider Demographics
NPI:1629253802
Name:JOHNSON, KIMBERLY E (PSYD, HSPP)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSYD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3955 EAGLE CREEK PKWY STE D
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-4692
Mailing Address - Country:US
Mailing Address - Phone:317-260-7223
Mailing Address - Fax:317-293-1241
Practice Address - Street 1:3955 EAGLE CREEK PKWY STE D
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-4692
Practice Address - Country:US
Practice Address - Phone:317-260-7223
Practice Address - Fax:317-293-1241
Is Sole Proprietor?:No
Enumeration Date:2008-01-07
Last Update Date:2019-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042216102L00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst