Provider Demographics
NPI:1568565174
Name:JOHNSON, CAROLYN H (PSY D)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:H
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 DONNA DRIVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-6188
Mailing Address - Country:US
Mailing Address - Phone:757-425-5050
Mailing Address - Fax:757-425-1389
Practice Address - Street 1:1630 DONNA DRIVE
Practice Address - Street 2:SUITE 102
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-6188
Practice Address - Country:US
Practice Address - Phone:757-425-5050
Practice Address - Fax:757-425-1389
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001859103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R65752Medicare UPIN