Provider Demographics
NPI:1225193568
Name:JOHNSON, RANDALL L (LMFT)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2390
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56302-2390
Mailing Address - Country:US
Mailing Address - Phone:320-650-1550
Mailing Address - Fax:320-650-1528
Practice Address - Street 1:911 18TH ST N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1203
Practice Address - Country:US
Practice Address - Phone:320-650-1550
Practice Address - Fax:320-650-1528
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1011106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist