MEDICARE: KEISHA HOLLEY JOHNSON PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	35188	TX

General Provider Information

NPI Number	:	1508144940
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEISHA HOLLEY JOHNSON PHD

Provider Business Mailing Address
First Line	:	11201 RICHMOND AVE STE A-111A
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77082-6653
Country	:	US
Telephone Number	:	281-512-4734
Fax Number	:	281-293-8100

Provider Business Practice Location Address
First Line	:	11201 RICHMOND AVE
Second Line	:	SUITE A-111A
City	:	HOUSTON
State	:	TX
Zip	:	77082-6653
Country	:	US
Telephone Number	:	281-512-4734
Fax Number	:	281-293-8100

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2011
Last Update Date	:	02/15/2019

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