Provider Demographics
NPI:1427874429
Name:JOHNSON, KEILAH
Entity type:Individual
Prefix:
First Name:KEILAH
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:KOENRAAD
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:996 ROYAL MARCO WAY
Mailing Address - Street 2:
Mailing Address - City:MARCO ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:34145-1829
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1675 18TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-5112
Practice Address - Country:US
Practice Address - Phone:970-400-9818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician