Provider Demographics
NPI:1336269356
Name:JOHNSON, KENNETH ROGER (MED)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:ROGER
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2539 SHETLAND RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43617-1635
Mailing Address - Country:US
Mailing Address - Phone:419-841-4108
Mailing Address - Fax:419-891-0356
Practice Address - Street 1:5757 MONCLOVA RD
Practice Address - Street 2:SUITE 16C
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1863
Practice Address - Country:US
Practice Address - Phone:419-893-0300
Practice Address - Fax:419-891-0356
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1023103TC0700X, 103TC2200X, 103TF0000X, 103TH0100X, 103TM1800X, 103T00000X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Not Answered103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Not Answered103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0253854Medicaid