Provider Demographics
NPI:1831911338
Name:JOHNSON, TANESHA RENAE (PHD)
Entity type:Individual
Prefix:DR
First Name:TANESHA
Middle Name:RENAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 ROSE STREET
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0001
Mailing Address - Country:US
Mailing Address - Phone:859-218-3744
Mailing Address - Fax:
Practice Address - Street 1:740 S LIMESTONE STE J233
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0001
Practice Address - Country:US
Practice Address - Phone:859-562-2597
Practice Address - Fax:859-218-7723
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-28
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY287651103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical