Provider Demographics
NPI:1700375623
Name:JOHNSON, TRICIA MAY (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:TRICIA
Middle Name:MAY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60
Mailing Address - Street 2:
Mailing Address - City:SAINT PETER
Mailing Address - State:MN
Mailing Address - Zip Code:56082-0060
Mailing Address - Country:US
Mailing Address - Phone:507-934-7788
Mailing Address - Fax:
Practice Address - Street 1:108 S MINNESOTA AVE STE 102
Practice Address - Street 2:
Practice Address - City:SAINT PETER
Practice Address - State:MN
Practice Address - Zip Code:56082-2557
Practice Address - Country:US
Practice Address - Phone:507-934-7788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN223351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical