MEDICARE: DR. CRIS WILLIAM JOHNSTON PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist	2470-057	WI
2	103G00000X	Clinical Neuropsychologist	LP 0160	MN

General Provider Information

NPI Number	:	1174512644
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CRIS WILLIAM JOHNSTON PH.D.

Provider Business Mailing Address
First Line	:	W9722 290TH AVE
Second Line	:
City	:	HAGER CITY
State	:	WI
Zip	:	54014-8349
Country	:	US
Telephone Number	:	715-262-5559
Fax Number	:

Provider Business Practice Location Address
First Line	:	115 ORANGE ST
Second Line	:
City	:	PRESCOTT
State	:	WI
Zip	:	54021-1728
Country	:	US
Telephone Number	:	715-262-5559
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/18/2005
Last Update Date	:	07/08/2007

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