Provider Demographics
NPI:1336200138
Name:JOHNSTON, ROSE M (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROSE
Middle Name:M
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 SOUTH YATES ROAD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-3707
Mailing Address - Country:US
Mailing Address - Phone:901-282-6136
Mailing Address - Fax:901-682-7136
Practice Address - Street 1:1027 SOUTH YATES ROAD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-3707
Practice Address - Country:US
Practice Address - Phone:901-282-6136
Practice Address - Fax:901-682-7136
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0000001415103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
3681774Medicare ID - Type Unspecified