Healthcare Provider Details

I. General information

NPI: 1710354451
Provider Name (Legal Business Name): MICHELE B. JOHNSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MICHELE L. BURTNER LCSW

II. Dates (important events)

Enumeration Date: 08/28/2015
Last Update Date: 08/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9950 COURTHOUSE RD
CHARLES CITY VA
23030-3434
US

IV. Provider business mailing address

PO BOX 1184
DUNNSVILLE VA
22454-1184
US

V. Phone/Fax

Practice location:
  • Phone: 804-829-6600
  • Fax: 804-829-6182
Mailing address:
  • Phone: 804-761-0838
  • Fax: 804-695-8173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904009080
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: