Provider Demographics
NPI:1346934072
Name:JOHNSON, KATHLEEN L (BS, LADC, CBIS)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:BS, LADC, CBIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 MARSCHALL RD STE 300
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-2690
Mailing Address - Country:US
Mailing Address - Phone:952-856-3932
Mailing Address - Fax:952-448-6047
Practice Address - Street 1:10990 95TH ST NE
Practice Address - Street 2:
Practice Address - City:OTSEGO
Practice Address - State:MN
Practice Address - Zip Code:55362-8149
Practice Address - Country:US
Practice Address - Phone:763-329-7195
Practice Address - Fax:952-448-6047
Is Sole Proprietor?:No
Enumeration Date:2023-06-06
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302203101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)