Provider Demographics
NPI:1558953695
Name:JOHNSON, MYKAYLA J
Entity Type:Individual
Prefix:
First Name:MYKAYLA
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 8TH ST S STE B
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792-3236
Mailing Address - Country:US
Mailing Address - Phone:218-404-8859
Mailing Address - Fax:218-748-8501
Practice Address - Street 1:910 8TH ST S STE B
Practice Address - Street 2:
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792-3236
Practice Address - Country:US
Practice Address - Phone:218-404-8859
Practice Address - Fax:218-748-8501
Is Sole Proprietor?:No
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician