Provider Demographics
NPI:1316955297
Name:JOHNSTON, GLORIA JEAN
Entity type:Individual
Prefix:MRS
First Name:GLORIA JEAN
Middle Name:
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GLORIA
Other - Middle Name:
Other - Last Name:FAIRHEAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW LCSW
Mailing Address - Street 1:PO BOX 396
Mailing Address - Street 2:5409 EVERYBODYS ROAD FOREST COUNTY POTAWATOMI HEALTH
Mailing Address - City:CRANDON
Mailing Address - State:WI
Mailing Address - Zip Code:54520
Mailing Address - Country:US
Mailing Address - Phone:715-478-4300
Mailing Address - Fax:715-478-4490
Practice Address - Street 1:5409 EVERYBODYS ROAD
Practice Address - Street 2:FOREST COUNTY POTAWATOMI HEALTH & WELLNESS CENTER
Practice Address - City:CRANDON
Practice Address - State:WI
Practice Address - Zip Code:54520
Practice Address - Country:US
Practice Address - Phone:715-478-4300
Practice Address - Fax:715-478-4490
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI65641231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI273386825009OtherBLUE CROSS BLUE SHIELD
WI69676OtherSECURITY HEALTH PLAN
WI39752800Medicaid