Provider Demographics
NPI:1295110773
Name:JOHNSON, KIMBERLY (MPT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 MAPLE AVENUE WEST
Mailing Address - Street 2:SUITE F
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180
Mailing Address - Country:US
Mailing Address - Phone:703-272-8801
Mailing Address - Fax:
Practice Address - Street 1:303 MAPLE AVE W
Practice Address - Street 2:SUITE F
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4312
Practice Address - Country:US
Practice Address - Phone:703-272-8801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-24
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305209427225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist