Provider Demographics
NPI:1902845241
Name:JOHNS, THERESA (LCSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:JOHNS
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 1:107 CRANES ROOST CT
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-3650
Mailing Address - Country:US
Mailing Address - Phone:270-765-2605
Mailing Address - Fax:270-234-8572
Practice Address - Street 1:331 S 3RD ST
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-1032
Practice Address - Country:US
Practice Address - Phone:502-348-9206
Practice Address - Fax:502-348-6485
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4672104100000X
KY2520301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000339368OtherANTHEM
KY30605018Medicaid