Provider Demographics
NPI:1932779709
Name:JOHNSON, KRISTEN M
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:M
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 1:145 LINCOLN LN
Mailing Address - Street 2:
Mailing Address - City:RUSTBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24588-3971
Mailing Address - Country:US
Mailing Address - Phone:434-300-8483
Mailing Address - Fax:
Practice Address - Street 1:701 THOMAS RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-1043
Practice Address - Country:US
Practice Address - Phone:434-616-6762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-25
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-21-162153106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician