Provider Demographics
NPI:1366627994
Name:JOHNSTON, THERESE ANNE
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:ANNE
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TERRY
Other - Middle Name:ANNE
Other - Last Name:JOHNSTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1152 CHERRY AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-3717
Mailing Address - Country:US
Mailing Address - Phone:408-292-4503
Mailing Address - Fax:408-286-3460
Practice Address - Street 1:1152 CHERRY AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125-3717
Practice Address - Country:US
Practice Address - Phone:408-292-4503
Practice Address - Fax:408-286-3460
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-02
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 4514103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic