Provider Demographics
NPI:1639404908
Name:JOHNSON, KATHERINE EILEEN (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:EILEEN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:EILEEN
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1101 W 40TH ST UNIT 2225
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37409-1379
Mailing Address - Country:US
Mailing Address - Phone:877-358-2998
Mailing Address - Fax:423-405-6346
Practice Address - Street 1:901 S 2ND ST STE 201
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-7909
Practice Address - Country:US
Practice Address - Phone:423-486-0774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0144041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT00015Medicare PIN