MEDICARE: MISS KEYONDA SHAYLA JOHNSON LPC RESIDENT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	212003001	VA
2	101YM0800X	Mental Health Counselor	0704016147	VA

General Provider Information

NPI Number	:	1033939285
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS KEYONDA SHAYLA JOHNSON LPC RESIDENT

Provider Business Mailing Address
First Line	:	3800 BELSPRING RD
Second Line	:
City	:	CHESTER
State	:	VA
Zip	:	23831-4612
Country	:	US
Telephone Number	:	804-252-0126
Fax Number	:

Provider Business Practice Location Address
First Line	:	3800 BELSPRING RD
Second Line	:
City	:	CHESTER
State	:	VA
Zip	:	23831-4612
Country	:	US
Telephone Number	:	804-252-0126
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/14/2024
Last Update Date	:	11/26/2024

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