Provider Demographics
NPI:1407180250
Name:JOHNSTON, COLLEEN ANN (LCSWR)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:ANN
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4561 WABASH RD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-9721
Mailing Address - Country:US
Mailing Address - Phone:585-526-4703
Mailing Address - Fax:
Practice Address - Street 1:4858 ROUTE 14A
Practice Address - Street 2:APT. E
Practice Address - City:HALL
Practice Address - State:NY
Practice Address - Zip Code:14463
Practice Address - Country:US
Practice Address - Phone:585-748-8699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-28
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYL73-0718101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical