Provider Demographics
NPI:1659363323
Name:JOHNSON, HOLLY ELLEN (PHD)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:ELLEN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4005 W 65TH ST
Mailing Address - Street 2:SUITE 118
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-1720
Mailing Address - Country:US
Mailing Address - Phone:952-929-7309
Mailing Address - Fax:952-929-7365
Practice Address - Street 1:4005 W 65TH ST
Practice Address - Street 2:SUITE 118
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-1720
Practice Address - Country:US
Practice Address - Phone:952-929-7309
Practice Address - Fax:952-929-7365
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2466103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist