Provider Demographics
NPI:1972128544
Name:JOHNSTON, MALLORY (MHP)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2103 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-4735
Mailing Address - Country:US
Mailing Address - Phone:618-214-2760
Mailing Address - Fax:
Practice Address - Street 1:4110 N WATER TOWER PL
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6295
Practice Address - Country:US
Practice Address - Phone:618-214-2760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health