Provider Demographics
NPI:1932208030
Name:JOHNSON, KEITH (LCPC)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 503861
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-0001
Mailing Address - Country:US
Mailing Address - Phone:618-436-8000
Mailing Address - Fax:618-241-3848
Practice Address - Street 1:444 N PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3006
Practice Address - Country:US
Practice Address - Phone:618-436-8000
Practice Address - Fax:618-241-3848
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional