1770623852 NPI number — KEIRSTEN ANNE JOHNSON-ROATH LCSW

Table of content: KEIRSTEN ANNE JOHNSON-ROATH LCSW (NPI 1770623852)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770623852 NPI number — KEIRSTEN ANNE JOHNSON-ROATH LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON-ROATH
Provider First Name:
KEIRSTEN
Provider Middle Name:
ANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1770623852
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
521 ELM DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLAINFIELD
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46168-2113
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-750-1177
Provider Business Mailing Address Fax Number:
317-839-8363

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3910 CLARKS CREEK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLAINFIELD
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46168-1947
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-750-1177
Provider Business Practice Location Address Fax Number:
317-839-8363
Provider Enumeration Date:
02/07/2007

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:  34004017A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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