Provider Demographics
NPI:1093366338
Name:JOHNSON, MALLORY (LPCC)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4536 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40214-1930
Mailing Address - Country:US
Mailing Address - Phone:859-760-2382
Mailing Address - Fax:
Practice Address - Street 1:11103 PARK RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-2424
Practice Address - Country:US
Practice Address - Phone:502-753-5524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-27
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY173555101YM0800X
KY265944101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health