1316955297 NPI number — MRS. GLORIA JEAN JOHNSTON

Table of content: MRS. GLORIA JEAN JOHNSTON (NPI 1316955297)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316955297 NPI number — MRS. GLORIA JEAN JOHNSTON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSTON
Provider First Name:
GLORIA JEAN
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FAIRHEAD
Provider Other First Name:
GLORIA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1316955297
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 396
Provider Second Line Business Mailing Address:
5409 EVERYBODYS ROAD FOREST COUNTY POTAWATOMI HEALTH
Provider Business Mailing Address City Name:
CRANDON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-478-4300
Provider Business Mailing Address Fax Number:
715-478-4490

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5409 EVERYBODYS ROAD
Provider Second Line Business Practice Location Address:
FOREST COUNTY POTAWATOMI HEALTH & WELLNESS CENTER
Provider Business Practice Location Address City Name:
CRANDON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-478-4300
Provider Business Practice Location Address Fax Number:
715-478-4490
Provider Enumeration Date:
08/04/2006

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: 1041C0700X , with the licence number:  6564123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 273386825009 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 69676 . This is a "SECURITY HEALTH PLAN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 39752800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".