Healthcare Provider Details

I. General information

NPI: 1306911078
Provider Name (Legal Business Name): DOUGLASS DAVID JOHNSTON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 FRONT ST
WYALUSING PA
18853-7505
US

IV. Provider business mailing address

PO BOX 174 114 MAIN STREET
WYALUSING PA
18853-0174
US

V. Phone/Fax

Practice location:
  • Phone: 570-746-6003
  • Fax: 570-746-2011
Mailing address:
  • Phone: 570-746-6003
  • Fax: 570-746-2011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW000365E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierSW000365E
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerSOCIAL WORK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: