Provider Demographics
NPI:1003597428
Name:JOHNSON, TINA MARIE (MSSW, MA, MPA)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSSW, MA, MPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4204 BOONES GROVE WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-7406
Mailing Address - Country:US
Mailing Address - Phone:502-314-4844
Mailing Address - Fax:
Practice Address - Street 1:204 E MARKET ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1218
Practice Address - Country:US
Practice Address - Phone:502-588-4340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker