Provider Demographics
NPI:1477671196
Name:JOHNSTON, TEDDY RAY (MA)
Entity Type:Individual
Prefix:MR
First Name:TEDDY
Middle Name:RAY
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4781 E GETTYSBURG AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-1814
Mailing Address - Country:US
Mailing Address - Phone:559-304-0514
Mailing Address - Fax:
Practice Address - Street 1:4781 E GETTYSBURG AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-1814
Practice Address - Country:US
Practice Address - Phone:559-304-0514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC45207106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist