Provider Demographics
NPI:1861969735
Name:JOHNSON, KAMIQUE MICHELLE (MHP, PHD)
Entity type:Individual
Prefix:
First Name:KAMIQUE
Middle Name:MICHELLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MHP, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2927 KING OAKS LOOP
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-4224
Mailing Address - Country:US
Mailing Address - Phone:318-780-2828
Mailing Address - Fax:866-343-8862
Practice Address - Street 1:609 REDWATER RD.
Practice Address - Street 2:
Practice Address - City:WAKE VILLAGE
Practice Address - State:TX
Practice Address - Zip Code:75501-7550
Practice Address - Country:US
Practice Address - Phone:903-501-8032
Practice Address - Fax:903-582-7338
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101YM0800X, 171M00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty