Provider Demographics
NPI:1457918427
Name:JOHNSON, DORLA (CEO)
Entity Type:Individual
Prefix:
First Name:DORLA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CEO
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 9641
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-9641
Mailing Address - Country:US
Mailing Address - Phone:757-609-8344
Mailing Address - Fax:855-423-7971
Practice Address - Street 1:3026 TYRE NECK RD STE J
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-4500
Practice Address - Country:US
Practice Address - Phone:757-609-8344
Practice Address - Fax:855-423-7971
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-23
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0732000554101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health