Provider Demographics
NPI:1427596543
Name:JOHNSON, NICOLETTE R (LPCC; LADC/LMAC)
Entity Type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPCC; LADC/LMAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 CEDARWOOD CT
Mailing Address - Street 2:
Mailing Address - City:WAITE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:56387-4504
Mailing Address - Country:US
Mailing Address - Phone:701-552-2992
Mailing Address - Fax:
Practice Address - Street 1:407 CEDARWOOD CT
Practice Address - Street 2:
Practice Address - City:WAITE PARK
Practice Address - State:MN
Practice Address - Zip Code:56387-4504
Practice Address - Country:US
Practice Address - Phone:701-552-2992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-09
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
MN2723101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)