Provider Demographics
NPI:1629771753
Name:JOHNSTON, SUMMER (BS)
Entity Type:Individual
Prefix:
First Name:SUMMER
Middle Name:
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 S HAWTHORNE RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202
Mailing Address - Country:US
Mailing Address - Phone:208-221-7899
Mailing Address - Fax:
Practice Address - Street 1:120 S HAWTHORNE RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202-8320
Practice Address - Country:US
Practice Address - Phone:208-221-7899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician