Provider Demographics
NPI:1295836492
Name:JOHNSON, BEVERLY JEAN (MALP)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:JEAN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MALP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5275 EDINA INDUSTRIAL BLVD STE 124
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439-2903
Mailing Address - Country:US
Mailing Address - Phone:952-926-3412
Mailing Address - Fax:952-926-3414
Practice Address - Street 1:5275 EDINA INDUSTRIAL BLVD STE 124
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-2903
Practice Address - Country:US
Practice Address - Phone:952-926-3412
Practice Address - Fax:952-926-3414
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2076103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist