Provider Demographics
NPI:1386350163
Name:JOHNSON, KIMBERLY S (RBT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6328 BUCKNELL CIR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-4420
Mailing Address - Country:US
Mailing Address - Phone:757-450-8507
Mailing Address - Fax:757-585-3544
Practice Address - Street 1:6328 BUCKNELL CIR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-4420
Practice Address - Country:US
Practice Address - Phone:757-450-8507
Practice Address - Fax:757-585-3544
Is Sole Proprietor?:No
Enumeration Date:2023-01-25
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA106S00000X
VARBT-23-264075106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician