Provider Demographics
NPI:1003634833
Name:JOHNSON, AL-NASIR MUHAMMAD ALI I
Entity type:Individual
Prefix:MR
First Name:AL-NASIR
Middle Name:MUHAMMAD ALI
Last Name:JOHNSON
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 CESAR CHAVEZ ST APT 233
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-2397
Mailing Address - Country:US
Mailing Address - Phone:612-477-6007
Mailing Address - Fax:
Practice Address - Street 1:88 CESAR CHAVEZ ST APT 233
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107-2397
Practice Address - Country:US
Practice Address - Phone:612-407-0047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNW383209086014103K00000X, 106E00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst