Provider Demographics
NPI:1053631622
Name:JOHNSON, HEATHER J (PSYD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 EXCELSIOR BLVD STE 411
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4977
Mailing Address - Country:US
Mailing Address - Phone:612-294-9458
Mailing Address - Fax:
Practice Address - Street 1:4601 EXCELSIOR BLVD STE 411
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-4977
Practice Address - Country:US
Practice Address - Phone:612-294-9458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-07
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TA0400X
MN5388103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN174658000Medicaid