Provider Demographics
NPI:1952185407
Name:JOHNSON, KEKE KOMEKO (CADC)
Entity Type:Individual
Prefix:
First Name:KEKE
Middle Name:KOMEKO
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 COFFMAN DR
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27863-9665
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 COFFMAN DR
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:NC
Practice Address - Zip Code:27863-9665
Practice Address - Country:US
Practice Address - Phone:919-581-7857
Practice Address - Fax:919-759-5012
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23518101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)