1881764702 NPI number — MARY JAYE KELLY JOHNSTON LPC-S

Table of content: MARY JAYE KELLY JOHNSTON LPC-S (NPI 1881764702)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881764702 NPI number — MARY JAYE KELLY JOHNSTON LPC-S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY JOHNSTON
Provider First Name:
MARY
Provider Middle Name:
JAYE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC-S
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KELLY-JOHNSTON
Provider Other First Name:
JAYE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC-S
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1881764702
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
355 LINWOOD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONROE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77304-4382
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-536-6503
Provider Business Mailing Address Fax Number:
936-447-6985

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
355 LINWOOD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONROE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77304-2007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-536-6503
Provider Business Practice Location Address Fax Number:
936-447-6985
Provider Enumeration Date:
11/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  15145 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 15145 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 161320001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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