Provider Demographics
NPI:1114531480
Name:JOHNSON, KIMBERLY ANNE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:593 NW YORK DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-7264
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:593 NW YORK DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-7264
Practice Address - Country:US
Practice Address - Phone:971-346-0355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-03
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTSLP-4434235Z00000X
ID235Z00000X
OR18242235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist