Provider Demographics
NPI:1285903096
Name:CORTINEZ, JOHNNY A (LCSW)
Entity type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:A
Last Name:CORTINEZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:JOHNNY
Other - Middle Name:A
Other - Last Name:CORTINAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1500 N WESTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-3318
Mailing Address - Country:US
Mailing Address - Phone:573-686-4151
Mailing Address - Fax:
Practice Address - Street 1:1500 N WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3318
Practice Address - Country:US
Practice Address - Phone:573-778-4746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-22
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX559201041C0700X, 104100000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker