Provider Demographics
NPI:1689690471
Name:JOHNSTON, MARY M (LSCW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:LSCW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 LAVISTA WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40219-2618
Mailing Address - Country:US
Mailing Address - Phone:502-969-2009
Mailing Address - Fax:
Practice Address - Street 1:2113 STATE ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4961
Practice Address - Country:US
Practice Address - Phone:812-949-3505
Practice Address - Fax:812-949-3505
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33801041C0700X
IN34004819A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200189820AMedicaid