Provider Demographics
NPI:1962954727
Name:JOHNSTON, CORRI
Entity type:Individual
Prefix:
First Name:CORRI
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 1:1 MARION ST
Mailing Address - Street 2:
Mailing Address - City:MALONE
Mailing Address - State:NY
Mailing Address - Zip Code:12953-1403
Mailing Address - Country:US
Mailing Address - Phone:518-483-7050
Mailing Address - Fax:
Practice Address - Street 1:23 HUSKIE LN
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-2450
Practice Address - Country:US
Practice Address - Phone:518-483-5230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY467190251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services