Provider Demographics
NPI:1629399746
Name:JOHNSON, BONITA RAE (LMFT)
Entity Type:Individual
Prefix:
First Name:BONITA
Middle Name:RAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8817 INVERNESS TER
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-1921
Mailing Address - Country:US
Mailing Address - Phone:763-424-8866
Mailing Address - Fax:763-424-8696
Practice Address - Street 1:7206 FORESTVIEW LN N # 210
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-5581
Practice Address - Country:US
Practice Address - Phone:763-201-1029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-14
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN997106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist