Healthcare Provider Details

I. General information

NPI: 1417749755
Provider Name (Legal Business Name): KEYONTA LATRISE JOHNSON- SIMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2025
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1871 WALLACE LAKE RD
WEST BEND WI
53090-9074
US

IV. Provider business mailing address

2144 N 33RD ST
MILWAUKEE WI
53208-1426
US

V. Phone/Fax

Practice location:
  • Phone: 414-915-1531
  • Fax:
Mailing address:
  • Phone: 414-915-1531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number0020200
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: