MEDICARE: MR. KEITH JOHNSON LCPC

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	101YP2500X	Professional Counselor		IL

General Provider Information

NPI Number	:	1932208030
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEITH JOHNSON LCPC

Provider Business Mailing Address
First Line	:	PO BOX 503861
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63150-0001
Country	:	US
Telephone Number	:	618-436-8000
Fax Number	:	618-241-3848

Provider Business Practice Location Address
First Line	:	444 N PLEASANT AVE
Second Line	:
City	:	CENTRALIA
State	:	IL
Zip	:	62801-3006
Country	:	US
Telephone Number	:	618-436-8000
Fax Number	:	618-241-3848

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

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	07/08/2007

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