Basic Information
| Provider Information | |||||||||
| NPI: | 1578955043 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KIMBERLEE | ||||||||
| MiddleName: | RAE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1315 NW MIRAGE LN APT H101 | ||||||||
| Address2: | |||||||||
| City: | SILVERDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983837603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099941534 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3214 W MCGRAW ST STE 212 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981993239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064534882 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2015 | ||||||||
| LastUpdateDate: | 02/20/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | CG 60483739 | WA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.