MEDICARE: TARA VERONICA JOHNSON MS, LPC

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	101YP2500X	Professional Counselor	0704006639	VA

General Provider Information

NPI Number	:	1790442572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA VERONICA JOHNSON MS, LPC

Provider Business Mailing Address
First Line	:	5738 TRAFALGAR PARK
Second Line	:
City	:	HENRICO
State	:	VA
Zip	:	23228-1811
Country	:	US
Telephone Number	:	804-537-2756
Fax Number	:	804-270-1088

Provider Business Practice Location Address
First Line	:	5230 HICKORY PARK DR STE A
Second Line	:
City	:	GLEN ALLEN
State	:	VA
Zip	:	23059-2628
Country	:	US
Telephone Number	:	804-322-9955
Fax Number	:	804-270-1088

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

Provider Enumeration Date	:	11/29/2021
Last Update Date	:	03/26/2025

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