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General NPI Number Information
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NPI Number | 1295788388
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Entity Type | Individual
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Provider Name | GEORGE 'BRICK' RETER JOHNSTONE PHD
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Gender | Male
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Dates
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Enumeration Date | 05/18/2006
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Last Update Date | 02/03/2022
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Provider Practice Location Address
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Address Line | 115 BUSINESS LOOP 70 W
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City | COLUMBIA
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State | MO
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Zip | 65203-3244
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Country | US
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Telephone | 573-882-1561
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Fax | 573-884-1889
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Provider Business Mailing Address
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Address Line | 2020 PEACHTREE RD NW
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City | ATLANTA
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State | GA
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Zip | 30309-1426
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Country | US
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Telephone | 404-367-1208
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Fax | 404-603-4441
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PSY004549
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PYR0266
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License Number State | MO
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