Provider Demographics
NPI:1376922690
Name:JOHNSTON, DESERAE (LMHC)
Entity Type:Individual
Prefix:
First Name:DESERAE
Middle Name:
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 MERIDA DR
Mailing Address - Street 2:
Mailing Address - City:ANTHONY
Mailing Address - State:NM
Mailing Address - Zip Code:88021-8225
Mailing Address - Country:US
Mailing Address - Phone:575-649-9327
Mailing Address - Fax:
Practice Address - Street 1:254 MERIDA DR
Practice Address - Street 2:
Practice Address - City:ANTHONY
Practice Address - State:NM
Practice Address - Zip Code:88021-8225
Practice Address - Country:US
Practice Address - Phone:575-649-9327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-19
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-0173791101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor