Provider Demographics
NPI:1811957194
Name:JOHNSON, KIMBERLY ANN (MA CCCSP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA CCCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 S ARMSTRONG AVE
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55355
Mailing Address - Country:US
Mailing Address - Phone:320-693-3969
Mailing Address - Fax:
Practice Address - Street 1:612 S ARMSTRONG AVE
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55355
Practice Address - Country:US
Practice Address - Phone:320-693-3969
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7214235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN257J9J0OtherBLUE CROSS BLUE SHIELD