Provider Demographics
NPI:1225247653
Name:JOHNSTON, WADE W (PSYD)
Entity Type:Individual
Prefix:DR
First Name:WADE
Middle Name:W
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1331
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-6331
Mailing Address - Country:US
Mailing Address - Phone:609-654-4455
Mailing Address - Fax:
Practice Address - Street 1:603 EUGENIA DRIVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-2311
Practice Address - Country:US
Practice Address - Phone:609-654-4455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00157000103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1728806Medicaid
NJWA453942Medicare ID - Type Unspecified