Provider Demographics
NPI:1861212300
Name:JOHNSTON, DERRICK (LRIC)
Entity type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:LRIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 S INDEPENDENCE BLVD STE 213
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-1150
Mailing Address - Country:US
Mailing Address - Phone:757-376-8167
Mailing Address - Fax:757-452-4447
Practice Address - Street 1:505 S INDEPENDENCE BLVD STE 213
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-1150
Practice Address - Country:US
Practice Address - Phone:757-376-8167
Practice Address - Fax:757-452-4447
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704017428101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health