Provider Demographics
NPI:1114346061
Name:JOHNSON, KEYA (LCSW, CCTP, CSOTP)
Entity Type:Individual
Prefix:
First Name:KEYA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW, CCTP, CSOTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 MOROSGO DR NE #14614
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-9840
Mailing Address - Country:US
Mailing Address - Phone:404-883-0724
Mailing Address - Fax:866-282-7377
Practice Address - Street 1:1770 INDIAN TRAIL RD
Practice Address - Street 2:SUITE 140
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-2627
Practice Address - Country:US
Practice Address - Phone:404-883-0724
Practice Address - Fax:866-282-7377
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-08
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19722104100000X
GACSW0062941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker