Healthcare Provider Details

I. General information

NPI: 1639404908
Provider Name (Legal Business Name): KATHERINE EILEEN JOHNSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHERINE EILEEN KENNEDY

II. Dates (important events)

Enumeration Date: 10/05/2009
Last Update Date: 05/09/2023
Certification Date: 05/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 S 2ND ST STE 201
SPRINGFIELD IL
62704-7909
US

IV. Provider business mailing address

1101 W 40TH ST UNIT 2225
CHATTANOOGA TN
37409-1379
US

V. Phone/Fax

Practice location:
  • Phone: 423-486-0774
  • Fax:
Mailing address:
  • Phone: 877-358-2998
  • Fax: 423-405-6346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.014404
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: