Provider Demographics
NPI:1740843119
Name:DURRETT JOHNSON, ELISHIA (LPCC)
Entity type:Individual
Prefix:
First Name:ELISHIA
Middle Name:
Last Name:DURRETT JOHNSON
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 32
Mailing Address - Street 2:
Mailing Address - City:PEWEE VALLEY
Mailing Address - State:KY
Mailing Address - Zip Code:40056
Mailing Address - Country:US
Mailing Address - Phone:502-379-5749
Mailing Address - Fax:866-611-3616
Practice Address - Street 1:802 STONE CREEK PARKWAY
Practice Address - Street 2:SUITE 2
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223
Practice Address - Country:US
Practice Address - Phone:502-379-5749
Practice Address - Fax:866-611-3616
Is Sole Proprietor?:No
Enumeration Date:2019-04-20
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY290710101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty