Provider Demographics
NPI:1457610149
Name:JOHNSON, KIMBERLY W (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:W
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1934 N 26TH W
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-5319
Mailing Address - Country:US
Mailing Address - Phone:208-317-5469
Mailing Address - Fax:
Practice Address - Street 1:1934 N 26TH W
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-5319
Practice Address - Country:US
Practice Address - Phone:208-317-5469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-15
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-4677101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health