Basic Information
Provider Information | |||||||||
NPI: | 1124002373 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HOPPER | ||||||||
FirstName: | THERESA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSW, LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2700 STANLEY GAULT PKWY STE 129 | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402235176 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5022534900 | ||||||||
FaxNumber: | 5024895751 | ||||||||
Practice Location | |||||||||
Address1: | 1 TRILLIUM WAY | ||||||||
Address2: |   | ||||||||
City: | CORBIN | ||||||||
State: | KY | ||||||||
PostalCode: | 407018727 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6065238521 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/01/2005 | ||||||||
LastUpdateDate: | 07/16/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCSW-185 | WY | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 252484 | KY | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 307090 | 01 | WY | BS OF WY | OTHER | 7100450820 | 05 | KY |   | MEDICAID | MH63 | 01 | WY | WINHEALTH PARTNERS | OTHER |