MEDICARE: DR. KIM L. JOHNSON PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	1796	AZ
2	103TC2200X	Clinical Child & Adolescent Psychologist	1796	AZ

General Provider Information

NPI Number	:	1881700961
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIM L. JOHNSON PH.D.

Provider Business Mailing Address
First Line	:	1930 S ALMA SCHOOL RD
Second Line	:	SUITE NUMBER B-214
City	:	MESA
State	:	AZ
Zip	:	85210-3064
Country	:	US
Telephone Number	:	480-491-5501
Fax Number	:

Provider Business Practice Location Address
First Line	:	1930 S ALMA SCHOOL RD
Second Line	:	SUITE NUMBER B-214
City	:	MESA
State	:	AZ
Zip	:	85210-3064
Country	:	US
Telephone Number	:	480-491-5501
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2006
Last Update Date	:	07/10/2007

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