Provider Demographics
NPI:1932374436
Name:JOHNSON, PATRICIA VANESSA (MS-EDS, NCC, LPC)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:VANESSA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS-EDS, NCC, LPC
Other - Prefix:MRS
Other - First Name:PATRICIA
Other - Middle Name:VANESSA
Other - Last Name:JOHNSON-CORNELIOUS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS-EDS, NCC, LPC
Mailing Address - Street 1:100 BILLINGSLEY RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1002
Mailing Address - Country:US
Mailing Address - Phone:704-927-8871
Mailing Address - Fax:704-376-2172
Practice Address - Street 1:100 BILLINGSLEY RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1002
Practice Address - Country:US
Practice Address - Phone:704-927-8871
Practice Address - Fax:704-376-2172
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-25
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6672101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health