Healthcare Provider Details

I. General information

NPI: 1760969455
Provider Name (Legal Business Name): MARQUETTA L JOHNSON LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2018
Last Update Date: 04/06/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 CUBA RD
MAYFIELD KY
42066-6809
US

IV. Provider business mailing address

1525 CUBA RD
MAYFIELD KY
42066-6809
US

V. Phone/Fax

Practice location:
  • Phone: 270-247-2588
  • Fax: 270-247-0142
Mailing address:
  • Phone: 270-247-2588
  • Fax: 270-247-0142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number261479
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number261479
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: