Provider Demographics
NPI:1184180465
Name:JOHNSTON, DIANE MARIE (LLPC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 DUNHAM DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48306-4804
Mailing Address - Country:US
Mailing Address - Phone:248-913-5290
Mailing Address - Fax:
Practice Address - Street 1:882 OAKMAN BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-3710
Practice Address - Country:US
Practice Address - Phone:313-875-7601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-12
Last Update Date:2019-11-14
Deactivation Date:2019-08-16
Deactivation Code:
Reactivation Date:2019-11-13
Provider Licenses
StateLicense IDTaxonomies
MI6401017050101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1184180465Medicaid