Provider Demographics
NPI:1811026511
Name:JOHNSTON, RAY THOMAS (LCSW, SAP)
Entity Type:Individual
Prefix:
First Name:RAY
Middle Name:THOMAS
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:LCSW, SAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207A BLOUNT ST
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-3541
Mailing Address - Country:US
Mailing Address - Phone:936-569-8570
Mailing Address - Fax:936-560-1144
Practice Address - Street 1:207A BLOUNT ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-3541
Practice Address - Country:US
Practice Address - Phone:936-569-8570
Practice Address - Fax:936-560-1144
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX104821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX089263002Medicaid
TX089263002Medicaid