Provider Demographics
NPI:1699389957
Name:JOHNSON, MICHELLE CHRISTINE (LSW)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:CHRISTINE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16786 JOPLIN WAY
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-5683
Mailing Address - Country:US
Mailing Address - Phone:952-836-7776
Mailing Address - Fax:
Practice Address - Street 1:8646 EAGLE CREEK CIR
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-1570
Practice Address - Country:US
Practice Address - Phone:952-583-1055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27037104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker