Provider Demographics
NPI:1154421550
Name:JOHNSTON, PERRY WILLIAM (MSW)
Entity type:Individual
Prefix:MR
First Name:PERRY
Middle Name:WILLIAM
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 NORTH MAYFAIR ROAD
Mailing Address - Street 2:SUITE 850 PARKLAND CLINIC
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226
Mailing Address - Country:US
Mailing Address - Phone:414-771-2088
Mailing Address - Fax:414-771-6308
Practice Address - Street 1:2600 N MAYFAIR RD
Practice Address - Street 2:SUITE 850
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-1309
Practice Address - Country:US
Practice Address - Phone:414-771-2088
Practice Address - Fax:414-771-6308
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI575-123103T00000X, 1041C0700X
WI435-124103T00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
084869005Medicare ID - Type Unspecified