Provider Demographics
NPI:1235818444
Name:JOHNSTON, CALLIE S
Entity Type:Individual
Prefix:
First Name:CALLIE
Middle Name:S
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85067 LIL WILLIAM RD
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-1241
Mailing Address - Country:US
Mailing Address - Phone:912-409-7903
Mailing Address - Fax:
Practice Address - Street 1:464099 STATE ROAD 200
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-6459
Practice Address - Country:US
Practice Address - Phone:904-875-4461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-14
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-282899106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician