Provider Demographics
NPI:1992862684
Name:JOHNSON, KIM DIXON (LP)
Entity Type:Individual
Prefix:MR
First Name:KIM
Middle Name:DIXON
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 APPALACHIAN ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-3121
Mailing Address - Country:US
Mailing Address - Phone:218-624-3697
Mailing Address - Fax:
Practice Address - Street 1:714 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-4906
Practice Address - Country:US
Practice Address - Phone:218-728-7164
Practice Address - Fax:218-724-0251
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 3401103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist