Provider Demographics
NPI:1508974635
Name:JOHNSTON, EDITH D (LPC)
Entity Type:Individual
Prefix:MS
First Name:EDITH
Middle Name:D
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:EDITH
Other - Middle Name:D
Other - Last Name:GALLENBECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:P.O. BOX 301
Mailing Address - Street 2:
Mailing Address - City:DELTA
Mailing Address - State:CO
Mailing Address - Zip Code:81416
Mailing Address - Country:US
Mailing Address - Phone:970-216-5753
Mailing Address - Fax:970-874-2840
Practice Address - Street 1:800 A ST
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:CO
Practice Address - Zip Code:81416-2627
Practice Address - Country:US
Practice Address - Phone:970-216-5753
Practice Address - Fax:970-874-2840
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2162101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO59920874Medicaid