Provider Demographics
NPI:1497135016
Name:JOHNSTONE, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:JOHNSTONE
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 1:1550 N MILFORD RD
Mailing Address - Street 2:SUITE NUMBER 205
Mailing Address - City:MILFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48381-1058
Mailing Address - Country:US
Mailing Address - Phone:248-840-0660
Mailing Address - Fax:248-562-3210
Practice Address - Street 1:1550 N MILFORD RD
Practice Address - Street 2:SUITE NUMBER 205
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48381-1058
Practice Address - Country:US
Practice Address - Phone:248-840-0660
Practice Address - Fax:248-562-3210
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009324103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical