Provider Demographics
NPI:1811299126
Name:JOHNSTON, SANDRA K (PHD, LP)
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:K
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 WYLDEWOOD DR
Mailing Address - Street 2:#B202
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-8631
Mailing Address - Country:US
Mailing Address - Phone:920-479-8178
Mailing Address - Fax:
Practice Address - Street 1:120 WYLDEWOOD DR
Practice Address - Street 2:#B202
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-8631
Practice Address - Country:US
Practice Address - Phone:920-479-8178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-19
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4407-125101YP2500X
WI15657-131101YA0400X
WI3184-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100015347Medicaid