Provider Demographics
NPI:1962145920
Name:JOHNSON, AVERY CENESE
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:CENESE
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 1:44 TWIN LAKES CIR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-2352
Mailing Address - Country:US
Mailing Address - Phone:757-646-2834
Mailing Address - Fax:
Practice Address - Street 1:110 COLISEUM XING
Practice Address - Street 2:STE 138
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-5971
Practice Address - Country:US
Practice Address - Phone:757-210-4233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1962069526OtherBOSS INNER CHILD COUNSELING