Provider Demographics
NPI:1578625893
Name:JOHNSON, KENNETH (LICSW)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 LAKEWOOD DR S
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55119-5522
Mailing Address - Country:US
Mailing Address - Phone:651-481-0664
Mailing Address - Fax:651-481-3907
Practice Address - Street 1:3570 LEXINGTON AVE N
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-8049
Practice Address - Country:US
Practice Address - Phone:651-481-0664
Practice Address - Fax:651-481-3907
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP34166OtherHEALTH PARTNERS