Provider Demographics
NPI:1639113574
Name:JOHNSON, JUANITA S (LPC)
Entity Type:Individual
Prefix:MS
First Name:JUANITA
Middle Name:S
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 1:1093 ASBURY CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:HALIFAX
Mailing Address - State:VA
Mailing Address - Zip Code:24558-2947
Mailing Address - Country:US
Mailing Address - Phone:434-476-7139
Mailing Address - Fax:
Practice Address - Street 1:20 W BANK ST
Practice Address - Street 2:SUITE 5
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-3279
Practice Address - Country:US
Practice Address - Phone:804-863-1689
Practice Address - Fax:804-863-1695
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA07010026101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA140491Medicaid
VA089366Medicaid
VA117957Medicaid
VA224111Medicaid