Provider Demographics
NPI:1952826166
Name:JOHNSTON, MARY CLAIRE (SLPA)
Entity Type:Individual
Prefix:MISS
First Name:MARY
Middle Name:CLAIRE
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2306 PARK PLACE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-6623
Mailing Address - Country:US
Mailing Address - Phone:940-782-0867
Mailing Address - Fax:940-782-0867
Practice Address - Street 1:404 RACQUET CLUB BLVD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-6408
Practice Address - Country:US
Practice Address - Phone:682-738-3056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-08
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX73430235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist