Provider Demographics
NPI:1427895853
Name:JOHNSTON, BREANNA
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8100 E 22ND ST N STE 100
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-2350
Mailing Address - Country:US
Mailing Address - Phone:316-239-8531
Mailing Address - Fax:
Practice Address - Street 1:8100 E 22ND ST N STE 100
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-2350
Practice Address - Country:US
Practice Address - Phone:316-239-8531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-12
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS03293103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical