Provider Demographics
NPI:1477004695
Name:PETERSON-OMOTOLA, MONA JUANITA (PHD LCPC-AC)
Entity Type:Individual
Prefix:DR
First Name:MONA
Middle Name:JUANITA
Last Name:PETERSON-OMOTOLA
Suffix:
Gender:F
Credentials:PHD LCPC-AC
Other - Prefix:
Other - First Name:MONA
Other - Middle Name:JUANITA
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD,LCPC-AC
Mailing Address - Street 1:7306 SUMMERTREE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23234-5935
Mailing Address - Country:US
Mailing Address - Phone:866-720-5321
Mailing Address - Fax:
Practice Address - Street 1:7400 BEAUFONT SPRINGS DRIVE SUITE 300
Practice Address - Street 2:
Practice Address - City:RICHMOND,
Practice Address - State:VA
Practice Address - Zip Code:23225
Practice Address - Country:US
Practice Address - Phone:866-720-5321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-24
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VANCCA14946101YA0400X
VA101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)