Basic Information
| Provider Information | |||||||||
| NPI: | 1366410102 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSTON | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | LISW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 177 LOWERY LN | ||||||||
| Address2: | |||||||||
| City: | NEW CONCORD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437629795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7408264376 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2500 JOHN GLENN HWY | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437259028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404549766 | ||||||||
| FaxNumber: | 7405886452 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 1041C0700X | I8573 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 000000340445 | 01 | OH | ANTHEM PIN | OTHER | 352005 | 01 | OH | TRICARE/MHN PIN | OTHER | 7372590 | 01 | OH | AETNA PIN | OTHER | Y08573 | 01 | OH | THE HEALTH PLAN PIN | OTHER |