Provider Demographics
NPI:1720356595
Name:JOHNSTON, AMANDA LANE (MS)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LANE
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 CUSTER ROAD
Mailing Address - Street 2:
Mailing Address - City:RUCHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080
Mailing Address - Country:US
Mailing Address - Phone:972-490-9055
Mailing Address - Fax:972-490-9058
Practice Address - Street 1:320 CUSTER ROAD
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080
Practice Address - Country:US
Practice Address - Phone:972-490-9055
Practice Address - Fax:972-490-9058
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
TX107458235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist