Healthcare Provider Details

I. General information

NPI: 1336269356
Provider Name (Legal Business Name): KENNETH ROGER JOHNSON M.ED
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5757 MONCLOVA RD SUITE 16C
MAUMEE OH
43537-1863
US

IV. Provider business mailing address

2539 SHETLAND RD
TOLEDO OH
43617-1635
US

V. Phone/Fax

Practice location:
  • Phone: 419-893-0300
  • Fax: 419-891-0356
Mailing address:
  • Phone: 419-841-4108
  • Fax: 419-891-0356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1023
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number1023
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number1023
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number1023
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number1023
License Number StateOH
# 6
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1023
License Number StateOH
# 7
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1023
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: