Healthcare Provider Details

I. General information

NPI: 1093364127
Provider Name (Legal Business Name): KRISTA SUSAN JOHNSTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2019
Last Update Date: 09/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 S HIGH ST
BRIDGTON ME
04009-1123
US

IV. Provider business mailing address

87 S HIGH ST
BRIDGTON ME
04009-1123
US

V. Phone/Fax

Practice location:
  • Phone: 207-647-5600
  • Fax:
Mailing address:
  • Phone: 207-647-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAC7063
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: