Provider Demographics
NPI:1790760023
Name:JOHNSTON, MARY HOLLIS (PHD)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:HOLLIS
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MS
Other - First Name:HOLLY
Other - Middle Name:
Other - Last Name:JOHNSTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4820 S GREENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-1914
Mailing Address - Country:US
Mailing Address - Phone:773-624-8181
Mailing Address - Fax:773-624-8181
Practice Address - Street 1:4820 S GREENWOOD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-1914
Practice Address - Country:US
Practice Address - Phone:773-624-8181
Practice Address - Fax:773-624-8181
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL923100Medicare ID - Type Unspecified