Provider Demographics
NPI:1144547704
Name:JOHNSTON, STACI R (BA)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:R
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 W KINGS RD
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-8042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1705 CRADDUCK RD
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-9491
Practice Address - Country:US
Practice Address - Phone:580-310-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-22
Last Update Date:2010-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor