=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699386185
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE A JOHNSTON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2020
-----------------------------------------------------
Last Update Date | 08/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12705 W SAN JUAN AVE
-----------------------------------------------------
City | LITCHFIELD PARK
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85340-4115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-764-3588
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8399 N 97TH DR
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85345-3710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-764-3588
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LAC-17525
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------