Provider Demographics
NPI:1821178799
Name:JOHNSON, PAMELA M (MA LP)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21206 BLUEBIRD DR
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-6218
Mailing Address - Country:US
Mailing Address - Phone:218-327-9336
Mailing Address - Fax:
Practice Address - Street 1:516 S POKEGAMA AVE
Practice Address - Street 2:SUITE B
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3800
Practice Address - Country:US
Practice Address - Phone:218-327-9336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3611103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist