Provider Demographics
NPI:1891363099
Name:JOHNSON, KEYDRA
Entity Type:Individual
Prefix:
First Name:KEYDRA
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 1:5711 BALTIMORE AVE APT 304
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20781-1670
Mailing Address - Country:US
Mailing Address - Phone:516-303-4535
Mailing Address - Fax:
Practice Address - Street 1:611 PENNSYLVANIA AVE SE # 415
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20003-4303
Practice Address - Country:US
Practice Address - Phone:202-643-6018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-14
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0953151041C0700X
DCLC2000026021041C0700X
DCLG50083757104100000X
NY103962104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker