Provider Demographics
NPI:1730157207
Name:JOHNSON, VICKI YVETTE (PSYD)
Entity type:Individual
Prefix:MS
First Name:VICKI
Middle Name:YVETTE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16354 RUSTY RUDDER DRIVE
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191
Mailing Address - Country:US
Mailing Address - Phone:703-398-9381
Mailing Address - Fax:703-441-1400
Practice Address - Street 1:17521 TRIPOLI BL.
Practice Address - Street 2:
Practice Address - City:DUMFRIES
Practice Address - State:VA
Practice Address - Zip Code:22026
Practice Address - Country:US
Practice Address - Phone:703-441-8000
Practice Address - Fax:703-441-1400
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-10
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC50077703104100000X
VA0810006968103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYVAD000Medicare UPIN