Healthcare Provider Details

I. General information

NPI: 1952546863
Provider Name (Legal Business Name): KIM L JOHNSON PHD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2008
Last Update Date: 12/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 S ALMA SCHOOL RD SUITE #B-214
MESA AZ
85210-3064
US

IV. Provider business mailing address

1930 S ALMA SCHOOL RD SUITE #B-214
MESA AZ
85210-3064
US

V. Phone/Fax

Practice location:
  • Phone: 480-491-5501
  • Fax:
Mailing address:
  • Phone: 480-491-5501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number1796
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number1796
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1796
License Number StateAZ

VIII. Authorized Official

Name: DR. KIM L JOHNSON
Title or Position: LICENSED PSYCHOLOGIST
Credential: PH.D.
Phone: 480-491-5501