Provider Demographics
NPI:1053687145
Name:JOHNSTON, HEATHER L (MSW)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 N COLISEUM BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-3139
Mailing Address - Country:US
Mailing Address - Phone:260-498-8009
Mailing Address - Fax:260-498-8009
Practice Address - Street 1:2420 N COLISEUM BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-3139
Practice Address - Country:US
Practice Address - Phone:260-498-8009
Practice Address - Fax:260-498-8009
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-22
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004652A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical