MEDICARE: DR. CAROLYN H JOHNSON PSY D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	0810001859	VA

General Provider Information

NPI Number	:	1568565174
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CAROLYN H JOHNSON PSY D

Provider Business Mailing Address
First Line	:	1630 DONNA DRIVE
Second Line	:	SUITE 102
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23451-6188
Country	:	US
Telephone Number	:	757-425-5050
Fax Number	:	757-425-1389

Provider Business Practice Location Address
First Line	:	1630 DONNA DRIVE
Second Line	:	SUITE 102
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23451-6188
Country	:	US
Telephone Number	:	757-425-5050
Fax Number	:	757-425-1389

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2006
Last Update Date	:	07/08/2007

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