Provider Demographics
NPI:1962874867
Name:JOHANCEN, KIM SUE
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:SUE
Last Name:JOHANCEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:JOHANCEN-WALT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:5795 S KITTREDGE CT
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80015-4029
Mailing Address - Country:US
Mailing Address - Phone:970-946-8737
Mailing Address - Fax:
Practice Address - Street 1:12835 E ARAPAHOE RD STE P-850
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-3940
Practice Address - Country:US
Practice Address - Phone:970-946-8737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-30
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0003285101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional