Healthcare Provider Details

I. General information

NPI: 1629993274
Provider Name (Legal Business Name): THEA DIONE JOHNSON LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 CHESTERFIELD AVE
CHARLESTON WV
25304-1126
US

IV. Provider business mailing address

2313 HARRISON AVE
SAINT ALBANS WV
25177-2005
US

V. Phone/Fax

Practice location:
  • Phone: 304-419-2247
  • Fax:
Mailing address:
  • Phone: 304-419-2247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberDP00943038
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: