Provider Demographics
NPI:1871002121
Name:HEATHER L JOHNSTON, LLC
Entity Type:Organization
Organization Name:HEATHER L JOHNSTON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:260-498-8009
Mailing Address - Street 1:2420 N COLISEUM BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-3139
Mailing Address - Country:US
Mailing Address - Phone:260-498-8009
Mailing Address - Fax:260-408-5309
Practice Address - Street 1:2420 N COLISEUM BLVD STE 201
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-3139
Practice Address - Country:US
Practice Address - Phone:260-498-8009
Practice Address - Fax:260-408-5309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004652A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty