Provider Demographics
NPI:1922481233
Name:JOHNSON, KASSIDI (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:KASSIDI
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 ROBINSON DRIVE
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76707
Mailing Address - Country:US
Mailing Address - Phone:254-732-2262
Mailing Address - Fax:254-732-2263
Practice Address - Street 1:3301 ROBINSON DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76706-4401
Practice Address - Country:US
Practice Address - Phone:254-732-2262
Practice Address - Fax:254-732-2263
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-06
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-13-14248103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst