Provider Demographics
NPI:1225508948
Name:JOHNSON, BRYAN ANN (LSW)
Entity Type:Individual
Prefix:MS
First Name:BRYAN
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:MS
Other - First Name:BRYAN
Other - Middle Name:ANN
Other - Last Name:COOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:704 E HOWARD ST STE C
Mailing Address - Street 2:
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-1744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:317 ARLINGTON RD
Practice Address - Street 2:
Practice Address - City:HOYT LAKES
Practice Address - State:MN
Practice Address - Zip Code:55750-1117
Practice Address - Country:US
Practice Address - Phone:218-780-6392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN17323104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty