Provider Demographics
NPI:1245548379
Name:JOHNSON, KIMBERLEE D (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:KIMBERLEE
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 931
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:VT
Mailing Address - Zip Code:05601-0931
Mailing Address - Country:US
Mailing Address - Phone:802-398-5317
Mailing Address - Fax:
Practice Address - Street 1:28 E. STATE STREET
Practice Address - Street 2:STE 8
Practice Address - City:MONTPELIER
Practice Address - State:VT
Practice Address - Zip Code:05602
Practice Address - Country:US
Practice Address - Phone:802-933-1964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-23
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089.01222381041C0700X
NCC0069281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1028186Medicaid
NC164P7OtherBCBSNC
NC6007881Medicaid