Provider Demographics
NPI:1912556952
Name:JOHNSON, BETH LAURIE (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:LAURIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11850 BLACKFOOT ST NW STE 130
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2583
Mailing Address - Country:US
Mailing Address - Phone:763-236-6061
Mailing Address - Fax:763-236-6065
Practice Address - Street 1:11850 BLACKFOOT ST NW STE 130
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2583
Practice Address - Country:US
Practice Address - Phone:763-236-6061
Practice Address - Fax:763-236-6065
Is Sole Proprietor?:No
Enumeration Date:2019-09-11
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN198341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical