Basic Information
| Provider Information | |||||||||
| NPI: | 1295788388 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSTONE | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | 'BRICK' RETER | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 PEACHTREE RD NW | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303091426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043671208 | ||||||||
| FaxNumber: | 4046034441 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 BUSINESS LOOP 70 W | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652033244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738821561 | ||||||||
| FaxNumber: | 5738841889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 02/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PSY004549 | GA | Y | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | PYR0266 | MO | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 131610 | 01 | MO | HEALTHLINK | OTHER | 6145989 | 01 | MO | UNITED HEALTHCARE | OTHER | 680002939 | 01 | MO | RR MEDICARE | OTHER | 13644 | 01 | MO | BLUE SHIELD/BLUE CHOICE | OTHER | 493401103 | 05 | MO | MEDICAID |