Provider Demographics
NPI:1386702736
Name:JOHNSON, SHELLY NICOLE (MA CAS LPC NCC)
Entity type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:NICOLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA CAS LPC NCC
Other - Prefix:MS
Other - First Name:SHELLY
Other - Middle Name:NICOLE
Other - Last Name:VANCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:72 CHESTNUT STREET
Mailing Address - Street 2:
Mailing Address - City:RIVESVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26588
Mailing Address - Country:US
Mailing Address - Phone:304-278-7250
Mailing Address - Fax:304-278-7250
Practice Address - Street 1:70 MARANATHA DRIVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554
Practice Address - Country:US
Practice Address - Phone:304-612-9499
Practice Address - Fax:304-278-7250
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1739101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor