Provider Demographics
NPI:1285188029
Name:JOHNSTON, MARY (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 WOODBURN RD
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-1202
Mailing Address - Country:US
Mailing Address - Phone:703-205-9452
Mailing Address - Fax:
Practice Address - Street 1:4020 PALMER PARK BLVD STE 101B
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-3433
Practice Address - Country:US
Practice Address - Phone:719-572-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040094061041C0700X
COCSW.099248281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical