Healthcare Provider Details

I. General information

NPI: 1235128570
Provider Name (Legal Business Name): SCOTT LOUCKS JOHNSTON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 TRIDENT WAY
SAN DIEGO CA
92155-4908
US

IV. Provider business mailing address

2139 FORT STOCKTON DR
SAN DIEGO CA
92103-1513
US

V. Phone/Fax

Practice location:
  • Phone: 619-537-5117
  • Fax:
Mailing address:
  • Phone: 619-537-5188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number795
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: