Provider Demographics
NPI:1639365547
Name:JOHNSTON, MARY ANNE (OTRL)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ANNE
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 W 44TH ST
Mailing Address - Street 2:TUSD AJO SERVICE CENTER
Mailing Address - City:TUSCON
Mailing Address - State:AZ
Mailing Address - Zip Code:85713
Mailing Address - Country:US
Mailing Address - Phone:520-908-5083
Mailing Address - Fax:
Practice Address - Street 1:2201 W 44TH ST
Practice Address - Street 2:TUSD AJO SERVICE CENTER
Practice Address - City:TUSCON
Practice Address - State:AZ
Practice Address - Zip Code:85713
Practice Address - Country:US
Practice Address - Phone:520-908-5083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0195225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ634916Medicaid