Provider Demographics
NPI:1740865906
Name:JOHNSON, KENNEDY PAIGE
Entity type:Individual
Prefix:
First Name:KENNEDY
Middle Name:PAIGE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 CONGRESSIONAL BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-5632
Mailing Address - Country:US
Mailing Address - Phone:317-249-2242
Mailing Address - Fax:
Practice Address - Street 1:12650 HAMILTON CROSSING BLVD
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-5400
Practice Address - Country:US
Practice Address - Phone:317-249-2242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-09
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
IN103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician