Provider Demographics
NPI:1427699909
Name:LAUTERBACH, TATJANA GABRIELLE (LCSW)
Entity type:Individual
Prefix:
First Name:TATJANA
Middle Name:GABRIELLE
Last Name:LAUTERBACH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:738 ANDRA DR
Mailing Address - Street 2:
Mailing Address - City:RADCLIFF
Mailing Address - State:KY
Mailing Address - Zip Code:40160-1880
Mailing Address - Country:US
Mailing Address - Phone:270-317-4165
Mailing Address - Fax:
Practice Address - Street 1:835 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:VINE GROVE
Practice Address - State:KY
Practice Address - Zip Code:40175-1562
Practice Address - Country:US
Practice Address - Phone:270-352-1133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-04
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY255320104100000X
KY2578381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker