Provider Demographics
NPI:1295788388
Name:JOHNSTONE, GEORGE 'BRICK' RETER (PHD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:'BRICK' RETER
Last Name:JOHNSTONE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 PEACHTREE RD NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1426
Mailing Address - Country:US
Mailing Address - Phone:404-367-1208
Mailing Address - Fax:404-603-4441
Practice Address - Street 1:115 BUSINESS LOOP 70 W
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-3244
Practice Address - Country:US
Practice Address - Phone:573-882-1561
Practice Address - Fax:573-884-1889
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY004549103T00000X
MOPYR0266103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO131610OtherHEALTHLINK
MO6145989OtherUNITED HEALTHCARE
MO680002939OtherRR MEDICARE
MO13644OtherBLUE SHIELD/BLUE CHOICE
MO493401103Medicaid
MO000070218Medicare PIN
MO680002939OtherRR MEDICARE
MO6145989OtherUNITED HEALTHCARE