Provider Demographics
NPI:1255413159
Name:JOHNSTON, SUSAN C (PSYD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 SW TAYLOR ST
Mailing Address - Street 2:SUITE 625
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2543
Mailing Address - Country:US
Mailing Address - Phone:503-227-3713
Mailing Address - Fax:
Practice Address - Street 1:1020 SW TAYLOR ST
Practice Address - Street 2:SUITE 625
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2543
Practice Address - Country:US
Practice Address - Phone:503-227-3713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0842103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR004478Medicaid