Provider Demographics
NPI:1992136352
Name:JOHNSON, KIMBERLY MICHELLE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MICHELLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:MICHELLE
Other - Last Name:HOUSTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:808 NW 141ST ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-1959
Mailing Address - Country:US
Mailing Address - Phone:405-487-9706
Mailing Address - Fax:
Practice Address - Street 1:808 NW 141ST ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-1959
Practice Address - Country:US
Practice Address - Phone:405-487-9706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-10
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor