Provider Demographics
NPI:1740553593
Name:JOHNSTON, AMANDA R
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:R
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 1:17502 HAMILWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77095-1118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17502 HAMILWOOD DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77095-1118
Practice Address - Country:US
Practice Address - Phone:505-330-8371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-09
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM120815521103TA0400X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM120815521OtherDRIVERS LICENSE NUMBER