MEDICARE: GUIDED GROWTH ABA CONSULTING AND THERAPY

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	101YM0800X	Mental Health Counselor
2	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1942175526
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GUIDED GROWTH ABA CONSULTING AND THERAPY

Provider Business Mailing Address
First Line	:	PO BOX 68685
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23471-8685
Country	:	US
Telephone Number	:	757-918-9481
Fax Number	:

Provider Business Practice Location Address
First Line	:	4605 PEMBROKE LAKE CIR STE 102
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23455-6435
Country	:	US
Telephone Number	:	757-918-9481
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	LAKISHA JOHNSON
Credential	:	LPC
Telephone Number	:	757-918-9481

Provider Enumeration Date	:	10/06/2025
Last Update Date	:	10/06/2025

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