Basic Information
| Provider Information | |||||||||
| NPI: | 1740476159 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSTON | ||||||||
| FirstName: | KELLEY | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 509 | ||||||||
| Address2: | |||||||||
| City: | PRESQUE ISLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047690509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077646825 | ||||||||
| FaxNumber: | 2077646077 | ||||||||
| Practice Location | |||||||||
| Address1: | 147 ACADEMY ST | ||||||||
| Address2: | |||||||||
| City: | PRESQUE ISLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047693101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077646825 | ||||||||
| FaxNumber: | 2077646077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2007 | ||||||||
| LastUpdateDate: | 10/07/2019 | ||||||||
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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 | 101YA0400X | CAC3787 | ME | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | ME | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | LC4577 | ME | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1740476159 | 05 | ME | MEDICAID |