Provider Demographics
NPI:1679902357
Name:JOHNSON, KIMBERLY ANN (MOT, OTR/L)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3452 LAKE LYNDA
Mailing Address - Street 2:#200
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3452 LAKE LYNDA
Practice Address - Street 2:#200
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-4727
Practice Address - Country:US
Practice Address - Phone:610-213-5244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119006103225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist