Provider Demographics
NPI:1699267054
Name:JOHNSTON, KARLY
Entity type:Individual
Prefix:
First Name:KARLY
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 1:16052 BEACH BLVD STE 218
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-3809
Mailing Address - Country:US
Mailing Address - Phone:657-845-1164
Mailing Address - Fax:
Practice Address - Street 1:16052 BEACH BLVD STE 218
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-3809
Practice Address - Country:US
Practice Address - Phone:657-845-1164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-01
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA133714106H00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program