Provider Demographics
NPI:1548702855
Name:JOHNSON, KIMERLYN (EDS)
Entity type:Individual
Prefix:
First Name:KIMERLYN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5450 BRUCE B DOWNS BLVD STE 328
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-8616
Mailing Address - Country:US
Mailing Address - Phone:813-766-4019
Mailing Address - Fax:
Practice Address - Street 1:1001 E BAKER ST
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563
Practice Address - Country:US
Practice Address - Phone:813-766-4019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-17
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health