Healthcare Provider Details

I. General information

NPI: 1144799636
Provider Name (Legal Business Name): SETH JOHNSTON MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2018
Last Update Date: 01/09/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2703 SE OTIS CORLEY DR
BENTONVILLE AR
72712-3864
US

IV. Provider business mailing address

2703 SE OTIS CORLEY DR
BENTONVILLE AR
72712-3864
US

V. Phone/Fax

Practice location:
  • Phone: 917-905-0139
  • Fax:
Mailing address:
  • Phone: 917-905-0139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-48450
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: