Provider Demographics
NPI:1063638427
Name:JOHNSON, LINDA JUNE (LP)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:JUNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4444 W LAKE HARRIET PKWY APT 9
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-1962
Mailing Address - Country:US
Mailing Address - Phone:612-285-7731
Mailing Address - Fax:651-633-5238
Practice Address - Street 1:2780 SNELLING AVE N STE 104
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-7115
Practice Address - Country:US
Practice Address - Phone:651-633-5290
Practice Address - Fax:651-633-5238
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4157103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN44177JOOtherBCBSM NON PAR PROVIDER #