Provider Demographics
NPI:1124002373
Name:HOPPER, THERESA M (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:HOPPER
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 STANLEY GAULT PKWY STE 129
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5176
Mailing Address - Country:US
Mailing Address - Phone:502-253-4900
Mailing Address - Fax:502-489-5751
Practice Address - Street 1:1 TRILLIUM WAY
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-8727
Practice Address - Country:US
Practice Address - Phone:606-523-8521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW-1851041C0700X
KY2524841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY307090OtherBS OF WY
KY7100450820Medicaid
WYMH63OtherWINHEALTH PARTNERS
WYMH63OtherWINHEALTH PARTNERS
KYK220150Medicare PIN