Provider Demographics
NPI:1558422923
Name:JOHNSTON, KRISTINE M (PHD)
Entity Type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:M
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:KRISTINE
Other - Middle Name:JOHNSTON
Other - Last Name:GERWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:130 LEWIS STREET
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-5538
Mailing Address - Country:US
Mailing Address - Phone:210-829-7471
Mailing Address - Fax:210-829-5398
Practice Address - Street 1:130 LEWIS STREET
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-5538
Practice Address - Country:US
Practice Address - Phone:210-829-7471
Practice Address - Fax:210-829-5398
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX228590103TF0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0332306-01Medicaid
TX00F79COtherMEDICARE
TXTXB154952OtherMEDICARE