Provider Demographics
NPI:1134232630
Name:JOHNSTON, DIANE LYNN (LCSW-R)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:LYNN
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:JOHNSTON
Other - Last Name:EGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW-R
Mailing Address - Street 1:5080 PARRISH STREET EXT
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-9178
Mailing Address - Country:US
Mailing Address - Phone:585-394-5824
Mailing Address - Fax:
Practice Address - Street 1:3019 COUNTY COMPLEX DR
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-9505
Practice Address - Country:US
Practice Address - Phone:585-396-4363
Practice Address - Fax:585-396-4993
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0332091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07300033209Medicaid
NY3109089OtherVALUE OPTIONS
NYEMOtherEXCELLUS
NY103283EUOtherPREFERRED CARE
NY10613DMedicare ID - Type UnspecifiedUPSTATE MEDICARE