Basic Information
Provider Information | |||||||||
NPI: | 1144715756 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOHNSTON | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | RAY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 301 EVERETT ST UNIT A | ||||||||
Address2: |   | ||||||||
City: | RUSTON | ||||||||
State: | LA | ||||||||
PostalCode: | 712703613 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3377946090 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1325 WRIGHT AVE STE D | ||||||||
Address2: |   | ||||||||
City: | CROWLEY | ||||||||
State: | LA | ||||||||
PostalCode: | 705262226 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3375145181 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/26/2018 | ||||||||
LastUpdateDate: | 06/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 13124 | LA | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 1041C0700X | 13124 | LA | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.