Provider Demographics
NPI:1699386185
Name:JOHNSTON, MICHELLE A
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:A
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:A
Other - Last Name:JENNINGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC, CSAT-C
Mailing Address - Street 1:8399 N 97TH DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-3710
Mailing Address - Country:US
Mailing Address - Phone:623-764-3588
Mailing Address - Fax:
Practice Address - Street 1:12705 W SAN JUAN AVE
Practice Address - Street 2:
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340-4115
Practice Address - Country:US
Practice Address - Phone:623-764-3588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-17525101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health