Provider Demographics
NPI:1588291454
Name:JOHNSTON, AWILDA VEGA (LPMFT)
Entity type:Individual
Prefix:
First Name:AWILDA
Middle Name:VEGA
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:LPMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:913 W THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-2539
Mailing Address - Country:US
Mailing Address - Phone:845-800-6299
Mailing Address - Fax:
Practice Address - Street 1:92 N. 2ND ST.
Practice Address - Street 2:#100
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069
Practice Address - Country:US
Practice Address - Phone:315-326-3555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-23
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP104680101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05Medicaid