Provider Demographics
NPI:1013356070
Name:JOHNSTON: SPEECH-LANGUAGE PATHOLOGY, PLLC
Entity Type:Organization
Organization Name:JOHNSTON: SPEECH-LANGUAGE PATHOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:607-206-6542
Mailing Address - Street 1:3129 E RIVER RD
Mailing Address - Street 2:
Mailing Address - City:NICHOLS
Mailing Address - State:NY
Mailing Address - Zip Code:13812-3224
Mailing Address - Country:US
Mailing Address - Phone:607-206-6542
Mailing Address - Fax:
Practice Address - Street 1:3129 E RIVER RD
Practice Address - Street 2:
Practice Address - City:NICHOLS
Practice Address - State:NY
Practice Address - Zip Code:13812-3224
Practice Address - Country:US
Practice Address - Phone:607-206-6542
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-22
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014024252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY014024OtherSLP LICENSE