Provider Demographics
NPI:1679705479
Name:JOHNSON, KIMBERLY PETRAE (LCSW)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:PETRAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:PETRAE
Other - Last Name:CRON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:315 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-1305
Mailing Address - Country:US
Mailing Address - Phone:859-312-6400
Mailing Address - Fax:
Practice Address - Street 1:137 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-1786
Practice Address - Country:US
Practice Address - Phone:859-312-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY32921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical