Healthcare Provider Details

I. General information

NPI: 1477004695
Provider Name (Legal Business Name): MONA JUANITA PETERSON-OMOTOLA PH.D. LCPC-AC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MONA JUANITA JONES PH.D.,LCPC-AC

II. Dates (important events)

Enumeration Date: 10/24/2016
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 BEAUFONT SPRINGS DRIVE SUITE 300
RICHMOND VA
23225
US

IV. Provider business mailing address

7306 SUMMERTREE DR
NORTH CHESTERFIELD VA
23234-5935
US

V. Phone/Fax

Practice location:
  • Phone: 866-720-5321
  • Fax:
Mailing address:
  • Phone: 866-720-5321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberNCCA14946
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: