Provider Demographics
NPI:1841383643
Name:JOHNSON, LYNNE ELLEN (MS LP)
Entity Type:Individual
Prefix:MS
First Name:LYNNE
Middle Name:ELLEN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4068 GREEN GABLES RD
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-7946
Mailing Address - Country:US
Mailing Address - Phone:218-829-6687
Mailing Address - Fax:218-829-9555
Practice Address - Street 1:523 N 3RD ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-3054
Practice Address - Country:US
Practice Address - Phone:218-828-7379
Practice Address - Fax:218-828-7390
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2864103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist