Healthcare Provider Details

I. General information

NPI: 1639436686
Provider Name (Legal Business Name): ELLEN M. JOHNSTON MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELLEN M. ZAMANSKY MA

II. Dates (important events)

Enumeration Date: 04/16/2012
Last Update Date: 09/17/2020
Certification Date: 09/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 HAY ST
FAYETTEVILLE NC
28305-5312
US

IV. Provider business mailing address

806 HAY ST
FAYETTEVILLE NC
28305-5312
US

V. Phone/Fax

Practice location:
  • Phone: 910-860-7008
  • Fax: 910-221-9006
Mailing address:
  • Phone: 910-860-7008
  • Fax: 910-221-9006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC 1174
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13322
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: