Provider Demographics
NPI:1881764702
Name:KELLY JOHNSTON, MARY JAYE (LPC-S)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JAYE
Last Name:KELLY JOHNSTON
Suffix:
Gender:F
Credentials:LPC-S
Other - Prefix:
Other - First Name:JAYE
Other - Middle Name:
Other - Last Name:KELLY-JOHNSTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC-S
Mailing Address - Street 1:355 LINWOOD
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-4382
Mailing Address - Country:US
Mailing Address - Phone:281-536-6503
Mailing Address - Fax:936-447-6985
Practice Address - Street 1:355 LINWOOD
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2007
Practice Address - Country:US
Practice Address - Phone:281-536-6503
Practice Address - Fax:936-447-6985
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15145101Y00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX161320001Medicaid