Basic Information
| Provider Information | |||||||||
| NPI: | 1336591668 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | BETHANY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 606 E MAIN ST | ||||||||
| Address2: | STE 2 | ||||||||
| City: | MADISON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472503689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123391691 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3008 BEVCHER DR | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472503863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122651918 | ||||||||
| FaxNumber: | 8122651828 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2016 | ||||||||
| LastUpdateDate: | 01/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 252265 | KY | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 34008720A | IN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 610661458 | 01 | KY | TAX ID | OTHER |