Provider Demographics
NPI:1770623852
Name:JOHNSON-ROATH, KEIRSTEN ANNE (LCSW)
Entity type:Individual
Prefix:
First Name:KEIRSTEN
Middle Name:ANNE
Last Name:JOHNSON-ROATH
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 1:521 ELM DR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-2113
Mailing Address - Country:US
Mailing Address - Phone:317-750-1177
Mailing Address - Fax:317-839-8363
Practice Address - Street 1:3910 CLARKS CREEK RD
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168-1947
Practice Address - Country:US
Practice Address - Phone:317-750-1177
Practice Address - Fax:317-839-8363
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004017A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical