Provider Demographics
NPI:1881382505
Name:JOHNSON, KEITH PHILLIP (PHD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:PHILLIP
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 E 38TH ST FL 15
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-2708
Mailing Address - Country:US
Mailing Address - Phone:212-263-6037
Mailing Address - Fax:
Practice Address - Street 1:240 E 38TH ST FL 15
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-2708
Practice Address - Country:US
Practice Address - Phone:212-263-6037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-01
Last Update Date:2023-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025658103T00000X, 103TH0004X, 103TR0400X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation