Provider Demographics
NPI:1164212221
Name:JOHNSON, KIMI
Entity type:Individual
Prefix:
First Name:KIMI
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 CROSS ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-4029
Mailing Address - Country:US
Mailing Address - Phone:541-808-1463
Mailing Address - Fax:
Practice Address - Street 1:705 CROSS ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-4029
Practice Address - Country:US
Practice Address - Phone:541-808-1463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-10
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
BACB748483103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
BACB748483OtherBCBA