Provider Demographics
NPI:1780937821
Name:JOHNSON, KEITH MICHAEL (CASAC)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:MICHAEL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16812 127TH AVE
Mailing Address - Street 2:APT # 7E
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-3152
Mailing Address - Country:US
Mailing Address - Phone:347-466-0698
Mailing Address - Fax:
Practice Address - Street 1:16812 127TH AVE
Practice Address - Street 2:APT # 7E
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-3152
Practice Address - Country:US
Practice Address - Phone:347-466-0698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY12777OtherC.A.S.A.C.