Healthcare Provider Details

I. General information

NPI: 1811299126
Provider Name (Legal Business Name): SANDRA K JOHNSTON PHD, LP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2010
Last Update Date: 09/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 WYLDEWOOD DR #B202
OSHKOSH WI
54904-8631
US

IV. Provider business mailing address

120 WYLDEWOOD DR #B202
OSHKOSH WI
54904-8631
US

V. Phone/Fax

Practice location:
  • Phone: 920-479-8178
  • Fax:
Mailing address:
  • Phone: 920-479-8178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15657-131
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4407-125
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3184-57
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: