Provider Demographics
NPI:1710160585
Name:HOLLY E. JOHNSON, P.H.D.,P.A.
Entity Type:Organization
Organization Name:HOLLY E. JOHNSON, P.H.D.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:952-929-7309
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 2466103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1659363323OtherNPI INDIVIDUAL NUMBER