Provider Demographics
NPI:1609525005
Name:JOHNSON, OLIVIA GRACE
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:GRACE
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 1:1775 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-2207
Mailing Address - Country:US
Mailing Address - Phone:320-774-3436
Mailing Address - Fax:320-774-3440
Practice Address - Street 1:1775 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-2207
Practice Address - Country:US
Practice Address - Phone:320-774-3436
Practice Address - Fax:320-774-3440
Is Sole Proprietor?:No
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician