Provider Demographics
NPI:1235158940
Name:JOHNSON, PAMELA (MA, LMFT, LP)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA, LMFT, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4775 DODD RD
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-2112
Mailing Address - Country:US
Mailing Address - Phone:612-719-5636
Mailing Address - Fax:651-846-4899
Practice Address - Street 1:1751 COUNTY ROAD B W STE 100
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4037
Practice Address - Country:US
Practice Address - Phone:612-719-5636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0541103T00000X
MN0736106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN62-20741OtherUBH
MN561853300Medicaid
MN104309OtherUC
MN570038OtherP1
MN0G042JOOtherBCBS
MN17621OtherHP