Provider Demographics
NPI:1497423479
Name:VON STADEN, JOANNA LISA (MA, LCMHCA, NCC)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:LISA
Last Name:VON STADEN
Suffix:
Gender:F
Credentials:MA, LCMHCA, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9541 JULIAN CLARK AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-3484
Mailing Address - Country:US
Mailing Address - Phone:980-358-1366
Mailing Address - Fax:
Practice Address - Street 1:9541 JULIAN CLARK AVE STE 100
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-3484
Practice Address - Country:US
Practice Address - Phone:980-358-1366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-02
Last Update Date:2022-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NCA16656101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC951767480PMedicaid