Provider Demographics
NPI: | 1942661764 |
---|---|
Name: | ECKENHOFF JOHNSON, KATE |
Entity Type: | Individual |
Prefix: | |
First Name: | KATE |
Middle Name: | |
Last Name: | ECKENHOFF JOHNSON |
Suffix: | |
Gender: | F |
Credentials: | |
Other - Prefix: | |
Other - First Name: | KATE |
Other - Middle Name: | |
Other - Last Name: | ECKENHOFF |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | |
Mailing Address - Street 1: | 2300 WALL ST |
Mailing Address - Street 2: | SUITE F |
Mailing Address - City: | CINCINNATI |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 45212-2781 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 513-834-7063 |
Mailing Address - Fax: | 513-429-4939 |
Practice Address - Street 1: | 2300 WALL ST |
Practice Address - Street 2: | SUITE F |
Practice Address - City: | CINCINNATI |
Practice Address - State: | OH |
Practice Address - Zip Code: | 45212 |
Practice Address - Country: | US |
Practice Address - Phone: | 513-834-7063 |
Practice Address - Fax: | 513-429-4939 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2016-03-08 |
Last Update Date: | 2018-05-31 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OH | LCDCIII.161545 | 171M00000X |
OH | CDCA.162903 | 101YA0400X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No | 171M00000X | Other Service Providers | Case Manager/Care Coordinator |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OH | 0271913 | Medicaid |