Provider Demographics
NPI:1144799636
Name:JOHNSTON, SETH (MS)
Entity Type:Individual
Prefix:
First Name:SETH
Middle Name:
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2703 SE OTIS CORLEY DR
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-3864
Mailing Address - Country:US
Mailing Address - Phone:917-905-0139
Mailing Address - Fax:
Practice Address - Street 1:2703 SE OTIS CORLEY DR
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3864
Practice Address - Country:US
Practice Address - Phone:917-905-0139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-14
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
AR1-21-48450103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR203528721Medicaid