Provider Demographics
NPI:1558661736
Name:JOHNSON, BETH A (MA)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 BARNES RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:41097-9483
Mailing Address - Country:US
Mailing Address - Phone:859-824-4442
Mailing Address - Fax:859-824-4448
Practice Address - Street 1:308 BARNES RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:KY
Practice Address - Zip Code:41097-9483
Practice Address - Country:US
Practice Address - Phone:859-824-4442
Practice Address - Fax:859-824-4448
Is Sole Proprietor?:No
Enumeration Date:2010-10-22
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1121101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY610661458OtherGROUP TAX ID NUMBER