Provider Demographics
NPI:1912757287
Name:JOHNSON, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
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 1:5107 US HIGHWAY 82 E
Mailing Address - Street 2:
Mailing Address - City:BLOSSOM
Mailing Address - State:TX
Mailing Address - Zip Code:75416-4161
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5107 US HIGHWAY 82 E
Practice Address - Street 2:
Practice Address - City:BLOSSOM
Practice Address - State:TX
Practice Address - Zip Code:75416-4161
Practice Address - Country:US
Practice Address - Phone:903-703-9483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
TX108288225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist