Basic Information
| Provider Information | |||||||||
| NPI: | 1174906135 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSTON | ||||||||
| FirstName: | CORY ANN | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 FOUNDERS PLZ | ||||||||
| Address2: | |||||||||
| City: | EAST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061083212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605695900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 FOUNDERS PLZ STE 1802 | ||||||||
| Address2: | |||||||||
| City: | EAST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061088301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605695900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2015 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 1041C0700X | 010091 | CT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.