Provider Demographics
NPI:1154639045
Name:JOHNSON-RATLIFF, THERESIA (LCSW)
Entity Type:Individual
Prefix:DR
First Name:THERESIA
Middle Name:
Last Name:JOHNSON-RATLIFF
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 ROSE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39203-2560
Mailing Address - Country:US
Mailing Address - Phone:601-988-5112
Mailing Address - Fax:
Practice Address - Street 1:251 ROSE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39203-2560
Practice Address - Country:US
Practice Address - Phone:601-988-5112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-14
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC05591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09924236Medicaid