Provider Demographics
NPI:1376718239
Name:JOHNSTON, MARY TERESE
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:TERESE
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 1:1115 BETHEL RD
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-2690
Mailing Address - Country:US
Mailing Address - Phone:614-538-0353
Mailing Address - Fax:
Practice Address - Street 1:1115 BETHEL RD
Practice Address - Street 2:1ST FLOOR
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-2690
Practice Address - Country:US
Practice Address - Phone:614-538-0353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC0600318101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional