MEDICARE: DR. IRMA B JOHNSTON PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	3652	OH

General Provider Information

NPI Number	:	1861487019
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IRMA B JOHNSTON PSYD

Provider Business Mailing Address
First Line	:	2600 FAR HILLS AVE
Second Line	:	STE 304
City	:	OAKWOOD
State	:	OH
Zip	:	45419-1687
Country	:	US
Telephone Number	:	937-299-0636
Fax Number	:	937-294-4669

Provider Business Practice Location Address
First Line	:	2600 FAR HILLS AVE
Second Line	:	STE 304
City	:	OAKWOOD
State	:	OH
Zip	:	45419-1687
Country	:	US
Telephone Number	:	937-299-0636
Fax Number	:	937-294-4669

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2005
Last Update Date	:	07/08/2007

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