Provider Demographics
NPI:1962860007
Name:JOHNSON, ELAINE BANHAM (BS)
Entity Type:Individual
Prefix:MRS
First Name:ELAINE
Middle Name:BANHAM
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41819 RYAN RD
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20148-6910
Mailing Address - Country:US
Mailing Address - Phone:703-327-6155
Mailing Address - Fax:
Practice Address - Street 1:120 BELLVIEW AVE
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-3142
Practice Address - Country:US
Practice Address - Phone:540-955-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-03
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst