Provider Demographics
NPI:1578802336
Name:JOHNSON, ALEX NICHOLAS COFFEY (MSW LICSW LADC)
Entity Type:Individual
Prefix:MR
First Name:ALEX
Middle Name:NICHOLAS COFFEY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MSW LICSW LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 OLEARY LN
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-2340
Mailing Address - Country:US
Mailing Address - Phone:651-454-0114
Mailing Address - Fax:651-454-3492
Practice Address - Street 1:3450 OLEARY LN
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-2340
Practice Address - Country:US
Practice Address - Phone:651-454-0114
Practice Address - Fax:651-454-3492
Is Sole Proprietor?:No
Enumeration Date:2013-02-13
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN218491041C0700X
MN302688101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400238503Medicare PIN