Healthcare Provider Details

I. General information

NPI: 1508974635
Provider Name (Legal Business Name): EDITH D JOHNSTON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: EDITH D GALLENBECK LPC

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 12/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 A ST
DELTA CO
81416-2627
US

IV. Provider business mailing address

P.O. BOX 301
DELTA CO
81416
US

V. Phone/Fax

Practice location:
  • Phone: 970-216-5753
  • Fax: 970-874-2840
Mailing address:
  • Phone: 970-216-5753
  • Fax: 970-874-2840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2162
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: