Provider Demographics
NPI:1417170374
Name:JOHNSON, BRADLEY D (LMFT)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:D
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 1:15798 VENTURE LN
Mailing Address - Street 2:SUITE 201
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-5729
Mailing Address - Country:US
Mailing Address - Phone:952-746-3883
Mailing Address - Fax:952-746-3894
Practice Address - Street 1:15798 VENTURE LN
Practice Address - Street 2:SUITE 201
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-5729
Practice Address - Country:US
Practice Address - Phone:952-746-3883
Practice Address - Fax:952-746-3894
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1209106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist