Provider Demographics
NPI:1972653921
Name:JOHNSON, LAURIE LEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 5TH ST SE STE 123C
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-4510
Mailing Address - Country:US
Mailing Address - Phone:651-457-1301
Mailing Address - Fax:
Practice Address - Street 1:1313 5TH ST SE STE 123C
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-4510
Practice Address - Country:US
Practice Address - Phone:651-457-1301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2231103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN68900JOOtherBLUE CROSS BLUE SHIELD MN