Provider Demographics
NPI:1821298878
Name:JOHNSTON, LISA J (PHD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:J
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 DAVIS RD
Mailing Address - Street 2:
Mailing Address - City:EAST AURORA
Mailing Address - State:NY
Mailing Address - Zip Code:14052-9752
Mailing Address - Country:US
Mailing Address - Phone:716-805-0081
Mailing Address - Fax:
Practice Address - Street 1:4211 N BUFFALO RD
Practice Address - Street 2:SUITE 18
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-2401
Practice Address - Country:US
Practice Address - Phone:716-805-0081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014542103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist