Basic Information
| Provider Information | |||||||||
| NPI: | 1962860007 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | ELAINE | ||||||||
| MiddleName: | BANHAM | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 41819 RYAN RD | ||||||||
| Address2: | |||||||||
| City: | ASHBURN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201486910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033276155 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 120 BELLVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226013142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409552400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2016 | ||||||||
| LastUpdateDate: | 02/03/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | VA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.