Healthcare Provider Details

I. General information

NPI: 1174512644
Provider Name (Legal Business Name): CRIS WILLIAM JOHNSTON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 ORANGE ST
PRESCOTT WI
54021-1728
US

IV. Provider business mailing address

W9722 290TH AVE
HAGER CITY WI
54014-8349
US

V. Phone/Fax

Practice location:
  • Phone: 715-262-5559
  • Fax:
Mailing address:
  • Phone: 715-262-5559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number2470-057
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberLP 0160
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: