Provider Demographics
NPI:1346394913
Name:JOHNSTON, MICHAEL D (PHD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:D
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:D
Other - Last Name:JOHNSTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:311 ALLUMBAUGH ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9208
Mailing Address - Country:US
Mailing Address - Phone:208-375-6402
Mailing Address - Fax:208-323-1850
Practice Address - Street 1:311 ALLUMBAUGH ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9208
Practice Address - Country:US
Practice Address - Phone:208-375-6402
Practice Address - Fax:208-323-1850
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-359103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0000100175OtherREGENCE BLUE SHIELD
IDN9535OtherBLUE CROSS
IDN9535OtherBLUE CROSS