Provider Demographics
NPI:1962500587
Name:JOHNSON, KIMBERLY C (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:C
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:KIMBELRY
Other - Middle Name:C
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:751 HEBRON PKWY
Mailing Address - Street 2:SUITE 305D
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-5055
Mailing Address - Country:US
Mailing Address - Phone:469-549-4200
Mailing Address - Fax:469-549-4201
Practice Address - Street 1:751 HEBRON PKWY
Practice Address - Street 2:SUITE 305D
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057-5055
Practice Address - Country:US
Practice Address - Phone:469-549-4200
Practice Address - Fax:469-549-4201
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32578103T00000X, 103G00000X
TX32698103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool