Provider Demographics
NPI:1700508009
Name:JOHNS, KACEY MATTHEW (LAC)
Entity Type:Individual
Prefix:MR
First Name:KACEY
Middle Name:MATTHEW
Last Name:JOHNS
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8805 BARBER ST
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72120-2981
Mailing Address - Country:US
Mailing Address - Phone:870-819-5799
Mailing Address - Fax:
Practice Address - Street 1:2504 MCCAIN BLVD STE 200
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-7612
Practice Address - Country:US
Practice Address - Phone:501-781-2230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2209000101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health