Provider Demographics
NPI:1740476159
Name:JOHNSTON, KELLEY A
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:A
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 509
Mailing Address - Street 2:
Mailing Address - City:PRESQUE ISLE
Mailing Address - State:ME
Mailing Address - Zip Code:04769-0509
Mailing Address - Country:US
Mailing Address - Phone:207-764-6825
Mailing Address - Fax:207-764-6077
Practice Address - Street 1:147 ACADEMY ST
Practice Address - Street 2:
Practice Address - City:PRESQUE ISLE
Practice Address - State:ME
Practice Address - Zip Code:04769-3101
Practice Address - Country:US
Practice Address - Phone:207-764-6825
Practice Address - Fax:207-764-6077
Is Sole Proprietor?:No
Enumeration Date:2007-09-19
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECAC3787101YA0400X
ME101YM0800X
MELC4577101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1740476159Medicaid