Provider Demographics
NPI:1982226635
Name:JOHNSTON, SELINA CAMILLE
Entity Type:Individual
Prefix:MS
First Name:SELINA
Middle Name:CAMILLE
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 BENFIELD BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:MILLERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21108-3004
Mailing Address - Country:US
Mailing Address - Phone:240-623-4684
Mailing Address - Fax:
Practice Address - Street 1:1111 BENFIELD BLVD STE 200
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-3004
Practice Address - Country:US
Practice Address - Phone:240-623-4684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-15
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21419104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD21419Medicaid