Provider Demographics
NPI:1245538180
Name:JOHANN, KATHLEEN MARIE (LCSW)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:MARIE
Last Name:JOHANN
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 1:5548 PAINTED MAPLE CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-9630
Mailing Address - Country:US
Mailing Address - Phone:317-902-2205
Mailing Address - Fax:
Practice Address - Street 1:7855 S EMERSON AVE STE H
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8669
Practice Address - Country:US
Practice Address - Phone:317-902-2205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-02
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN3304149A104100000X
IN34006255A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker