Healthcare Provider Details

I. General information

NPI: 1619213030
Provider Name (Legal Business Name): BRANDY ST JOHN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2012
Last Update Date: 03/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 HAMILTON BLVD
SOUTH BOSTON VA
24592-5200
US

IV. Provider business mailing address

PO BOX 1478
CLARKSVILLE VA
23927-1478
US

V. Phone/Fax

Practice location:
  • Phone: 434-572-4863
  • Fax: 434-572-4978
Mailing address:
  • Phone: 434-572-6916
  • Fax: 434-374-3321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701006492
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: