Provider Demographics
NPI:1760681985
Name:JOHNSTON, ROY ALAN (LISAC)
Entity Type:Individual
Prefix:MR
First Name:ROY
Middle Name:ALAN
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4041 N. CENTRAL AVE
Mailing Address - Street 2:BUILDING C
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-3133
Mailing Address - Country:US
Mailing Address - Phone:602-279-5262
Mailing Address - Fax:602-279-5390
Practice Address - Street 1:4041 N. CENTRAL AVE
Practice Address - Street 2:BUILDING C
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-3133
Practice Address - Country:US
Practice Address - Phone:602-279-5262
Practice Address - Fax:602-279-5390
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC11403101YA0400X
AZLISAC-11403101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ910217Medicaid