Provider Demographics
NPI:1891930087
Name:JOHNSON, BRADLEY OWEN (LMFT)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:OWEN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD NW
Mailing Address - Street 2:SUITE 110
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1786
Mailing Address - Country:US
Mailing Address - Phone:651-628-4993
Mailing Address - Fax:
Practice Address - Street 1:1900 SILVER LAKE RD NW
Practice Address - Street 2:SUITE 110
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-1786
Practice Address - Country:US
Practice Address - Phone:651-628-4993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-02
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1334106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist