Provider Demographics
NPI:1003562018
Name:JOHANNESON, MARYA M (MA)
Entity Type:Individual
Prefix:
First Name:MARYA
Middle Name:M
Last Name:JOHANNESON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:482 WILDERNESS DR
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-1577
Mailing Address - Country:US
Mailing Address - Phone:952-292-7459
Mailing Address - Fax:
Practice Address - Street 1:6001 EGAN DR STE 197
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-2099
Practice Address - Country:US
Practice Address - Phone:952-592-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty