Provider Demographics
NPI:1639168446
Name:JOHNSON, CYNTHIA LYNNE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:LYNNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 SMITH AVE N, MAIL ROUTE 60222
Mailing Address - Street 2:
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102
Mailing Address - Country:US
Mailing Address - Phone:651-241-8565
Mailing Address - Fax:651-241-7168
Practice Address - Street 1:333 SMITH AVE N, MAIL ROUTE 60222
Practice Address - Street 2:
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102
Practice Address - Country:US
Practice Address - Phone:651-241-8565
Practice Address - Fax:651-241-7168
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-14
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3230103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2147165Medicaid