Provider Demographics
NPI:1730652256
Name:JOHNSTON, TODD (LADC)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11325 RHODE ISLAND AVE N
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-3229
Mailing Address - Country:US
Mailing Address - Phone:612-801-0919
Mailing Address - Fax:
Practice Address - Street 1:11325 RHODE ISLAND AVE N
Practice Address - Street 2:
Practice Address - City:CHAMPLIN
Practice Address - State:MN
Practice Address - Zip Code:55316-3229
Practice Address - Country:US
Practice Address - Phone:612-801-0919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300224101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)