Provider Demographics
NPI:1881880086
Name:JOHNSTON, TIFFANY P (SLP)
Entity type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:P
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:MISS
Other - First Name:TIFFANY
Other - Middle Name:P
Other - Last Name:LUNDEEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:PRESQUE ISLE
Mailing Address - State:ME
Mailing Address - Zip Code:04769-0308
Mailing Address - Country:US
Mailing Address - Phone:207-764-4498
Mailing Address - Fax:207-764-1912
Practice Address - Street 1:79 BLAKE ST
Practice Address - Street 2:
Practice Address - City:PRESQUE ISLE
Practice Address - State:ME
Practice Address - Zip Code:04769-2474
Practice Address - Country:US
Practice Address - Phone:207-764-4101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEST1737235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432291999Medicaid