Provider Demographics
NPI:1114062510
Name:JOHNSON, VICKI (MA, LMFT)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13911 RIDGEDALE DR
Mailing Address - Street 2:SUITE 330
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-1771
Mailing Address - Country:US
Mailing Address - Phone:952-545-2063
Mailing Address - Fax:
Practice Address - Street 1:13911 RIDGEDALE DR
Practice Address - Street 2:SUITE 330
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1771
Practice Address - Country:US
Practice Address - Phone:952-545-2063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0375106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist