1124002373 NPI number — THERESA M HOPPER MSW, LCSW

Table of content: THERESA M HOPPER MSW, LCSW (NPI 1124002373)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124002373 NPI number — THERESA M HOPPER MSW, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOPPER
Provider First Name:
THERESA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW, LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124002373
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2700 STANLEY GAULT PKWY STE 129
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40223-5176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-253-4900
Provider Business Mailing Address Fax Number:
502-489-5751

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 TRILLIUM WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORBIN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40701-8727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-523-8521
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LCSW-185 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 252484 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 307090 . This is a "BS OF WY" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100450820 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: MH63 . This is a "WINHEALTH PARTNERS" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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