Provider Demographics
NPI:1356530109
Name:JOHNSON, RICHARD MATTHEW (SERVICE COORDINATOR)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:MATTHEW
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:SERVICE COORDINATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:384 PASCOE BLVD
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-5442
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:380 SUWANNEE TRAIL STREET
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103
Practice Address - Country:US
Practice Address - Phone:270-901-5000
Practice Address - Fax:270-782-5927
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30604011Medicaid