Provider Demographics
NPI:1407372337
Name:JOHNSTON, NATHANIEL JAMES JR (MA, MA)
Entity Type:Individual
Prefix:MR
First Name:NATHANIEL
Middle Name:JAMES
Last Name:JOHNSTON
Suffix:JR
Gender:M
Credentials:MA, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 MAITLAND CENTER COMMONS BLVD STE 212
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7270
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14556 EDGEMERE DR
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34609-0684
Practice Address - Country:US
Practice Address - Phone:352-942-0454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-22
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008332900Medicaid