Provider Demographics
NPI:1699309864
Name:JOHNSON, LEAH I
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:I
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1476 PATRICK HENRY AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE COURT HOUSE
Mailing Address - State:VA
Mailing Address - Zip Code:23923-3733
Mailing Address - Country:US
Mailing Address - Phone:443-820-6837
Mailing Address - Fax:
Practice Address - Street 1:1476 PATRICK HENRY AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE COURT HOUSE
Practice Address - State:VA
Practice Address - Zip Code:23923-3733
Practice Address - Country:US
Practice Address - Phone:443-820-6837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-26
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC13066101YP2500X
NCA15668101YM0800X
MDLGP9979390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program