Provider Demographics
NPI:1023026200
Name:JOHNSTON, MARK C (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:C
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 BOYLSTON ST
Mailing Address - Street 2:RASI ASSOCIATES - 2ND FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-3604
Mailing Address - Country:US
Mailing Address - Phone:617-266-2266
Mailing Address - Fax:617-266-6070
Practice Address - Street 1:607 BOYLSTON ST
Practice Address - Street 2:RASI ASSOCIATES - 2ND FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-3604
Practice Address - Country:US
Practice Address - Phone:617-266-2266
Practice Address - Fax:617-266-6070
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7902103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RA W40038Medicare ID - Type UnspecifiedGROUP MEDICARE PART B