Provider Demographics
NPI:1710354451
Name:JOHNSON, MICHELE B (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:B
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:L
Other - Last Name:BURTNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 1184
Mailing Address - Street 2:
Mailing Address - City:DUNNSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22454-1184
Mailing Address - Country:US
Mailing Address - Phone:804-761-0838
Mailing Address - Fax:804-695-8173
Practice Address - Street 1:9950 COURTHOUSE RD
Practice Address - Street 2:
Practice Address - City:CHARLES CITY
Practice Address - State:VA
Practice Address - Zip Code:23030-3434
Practice Address - Country:US
Practice Address - Phone:804-829-6600
Practice Address - Fax:804-829-6182
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-28
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040090801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1497717615Medicaid