Healthcare Provider Details

I. General information

NPI: 1770623852
Provider Name (Legal Business Name): KEIRSTEN ANNE JOHNSON-ROATH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3910 CLARKS CREEK RD
PLAINFIELD IN
46168-1947
US

IV. Provider business mailing address

521 ELM DR
PLAINFIELD IN
46168-2113
US

V. Phone/Fax

Practice location:
  • Phone: 317-750-1177
  • Fax: 317-839-8363
Mailing address:
  • Phone: 317-750-1177
  • Fax: 317-839-8363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34004017A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: