Provider Demographics
NPI:1639436686
Name:JOHNSTON, ELLEN M (MA)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:M
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:ELLEN
Other - Middle Name:M
Other - Last Name:ZAMANSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:806 HAY ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-5312
Mailing Address - Country:US
Mailing Address - Phone:910-860-7008
Mailing Address - Fax:910-221-9006
Practice Address - Street 1:806 HAY ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5312
Practice Address - Country:US
Practice Address - Phone:910-860-7008
Practice Address - Fax:910-221-9006
Is Sole Proprietor?:No
Enumeration Date:2012-04-16
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC 1174101YP2500X
NC13322101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLPC1174OtherSTATE LICENSE