MEDICARE: KELLEY A JOHNSTON

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	CAC3787	ME
2	101YM0800X	Mental Health Counselor		ME
3	101YA0400X	Addiction (Substance Use Disorder) Counselor	LC4577	ME

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1740476159
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLEY A JOHNSTON

Provider Business Mailing Address
First Line	:	PO BOX 509
Second Line	:
City	:	PRESQUE ISLE
State	:	ME
Zip	:	04769-0509
Country	:	US
Telephone Number	:	207-764-6825
Fax Number	:	207-764-6077

Provider Business Practice Location Address
First Line	:	147 ACADEMY ST
Second Line	:
City	:	PRESQUE ISLE
State	:	ME
Zip	:	04769-3101
Country	:	US
Telephone Number	:	207-764-6825
Fax Number	:	207-764-6077

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

Provider Enumeration Date	:	09/19/2007
Last Update Date	:	10/07/2019

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Directions to “ KELLEY A JOHNSTON ” Practice Location

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