Provider Demographics
NPI:1285974329
Name:JOHNSON, ELLEN E (LICSW)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 PENN AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55411-3047
Mailing Address - Country:US
Mailing Address - Phone:612-543-2731
Mailing Address - Fax:612-677-6346
Practice Address - Street 1:1313 PENN AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411-3047
Practice Address - Country:US
Practice Address - Phone:612-543-2731
Practice Address - Fax:612-677-6346
Is Sole Proprietor?:No
Enumeration Date:2013-02-27
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN209171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MNENROLLEDMedicaid