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General NPI Number Information
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NPI Number | 1457918427
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Entity Type | Individual
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Provider Name | DORLA JOHNSON CEO
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Gender | Female
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Dates
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Enumeration Date | 05/23/2019
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Last Update Date | 10/26/2020
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Provider Practice Location Address
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Address Line | 3026 TYRE NECK RD STE J
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City | PORTSMOUTH
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State | VA
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Zip | 23703-4500
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Country | US
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Telephone | 757-609-8344
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Fax | 855-423-7971
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Provider Business Mailing Address
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Address Line | PO BOX 9641
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City | CHESAPEAKE
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State | VA
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Zip | 23321-9641
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Country | US
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Telephone | 757-609-8344
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Fax | 855-423-7971
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 0732000554
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License Number State | VA
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