Provider Demographics
NPI:1679988653
Name:JOHNSON, KENNETH (LBS)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 HERR ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17103-1815
Mailing Address - Country:US
Mailing Address - Phone:717-230-9622
Mailing Address - Fax:
Practice Address - Street 1:2601 HERR ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17103-1815
Practice Address - Country:US
Practice Address - Phone:717-230-9622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-27
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH002026103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst