Healthcare Provider Details

I. General information

NPI: 1043802580
Provider Name (Legal Business Name): KIMBERLEY K JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2021
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 S 9TH ST
LEESBURG FL
34748-6320
US

IV. Provider business mailing address

1650 SAND LAKE RD STE 230
ORLANDO FL
32809-9138
US

V. Phone/Fax

Practice location:
  • Phone: 407-530-5063
  • Fax: 888-975-0599
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: