Provider Demographics
NPI:1770236812
Name:MADDIE JOHNSON, LLC
Entity Type:Organization
Organization Name:MADDIE JOHNSON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MADELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:847-525-8852
Mailing Address - Street 1:3659 MAIN ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-1133
Mailing Address - Country:US
Mailing Address - Phone:847-525-8852
Mailing Address - Fax:
Practice Address - Street 1:11292 86TH AVE N # 10655369
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4510
Practice Address - Country:US
Practice Address - Phone:507-774-0731
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-29
Last Update Date:2022-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health