Provider Demographics
NPI:1619511532
Name:JOHNSON, MARVA E (LPC)
Entity Type:Individual
Prefix:
First Name:MARVA
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2472
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28302-2472
Mailing Address - Country:US
Mailing Address - Phone:818-231-1424
Mailing Address - Fax:
Practice Address - Street 1:996 HELEN ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-3069
Practice Address - Country:US
Practice Address - Phone:910-635-0115
Practice Address - Fax:910-824-7593
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-04
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15328101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty