Healthcare Provider Details

I. General information

NPI: 1558422923
Provider Name (Legal Business Name): KRISTINE M JOHNSTON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KRISTINE JOHNSTON GERWELL PH.D

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 10/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 LEWIS STREET
SAN ANTONIO TX
78212-5538
US

IV. Provider business mailing address

130 LEWIS STREET
SAN ANTONIO TX
78212-5538
US

V. Phone/Fax

Practice location:
  • Phone: 210-829-7471
  • Fax: 210-829-5398
Mailing address:
  • Phone: 210-829-7471
  • Fax: 210-829-5398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number228590
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number228590
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: